Heart Failure Exercise And Training Camp: effects of a multicomponent exercise training intervention in patients with heart failure

Cardiac Rehabilitation and Heart Failure with Reduced Ejection Fraction: Pathophysiology, Benefits, and Precautions

Heart failure (HF) is a highly comorbid condition associated with significant mortality, despite advances in current medical management. Patients who suffer from HF represent a high needs disease care population in whom structured, long-term chronic disease care delivery models, such as cardiac rehabilitation (CR), have been shown to be highly cost effective in reducing hospitalizations and improving quality of life. HF with reduced ejection fraction affects a growing number of Canadians and health care costs secondary to this condition are increasing, with further increases over the next decade to be expected. CR is a guideline-directed medical therapy for patients living with HF with reduced ejection fraction, and with increasing numbers of HF patients across the world, there is a prescient need to revisit the benefits, safety, and the prescription of this intervention for the health care professionals who treat this condition. Certainly, there is a clinical need for HF practitioners to better understand the pathophysiological benefits of CR with respect to exercise training, as well as the prudent precautions required to facilitate the safe delivery of this highly cost-effective patient intervention.

Impact of Long-Term Exercise-Based Cardiac Rehabilitation in Patients With Chronic Heart Failure - A Systematic Review and Meta-Analysis

BACKGROUND

This study aimed to clarify the effects of exercise-based cardiac rehabilitation (CR) on patients with heart failure.

METHODS AND RESULTS

Patients were divided into groups according to intervention duration (<6 and ≥6 months). We searched for studies published up to July 2023 in Embase, MEDLINE, PubMed, and the Cochrane Library, without limitations on data, language, or publication status. We included randomized controlled trials comparing the efficacy of CR and usual care on mortality, prehospitalization, peak oxygen uptake (V̇O2), and quality of life. Seventy-two studies involving 8,495 patients were included in this review. It was found that CR reduced the risk of rehospitalization for any cause (risk ratio [RR] 0.80; 95% confidence interval [CI] 0.70-0.92) and for heart failure (RR 0.88; 95% CI 0.78-1.00). Furthermore, CR was found to improve exercise tolerance (measured by peak V̇O2and the 6-min walk test) and quality of life. A subanalysis performed based on intervention duration (<6 and ≥6 months) revealed a similar trend.

CONCLUSIONS

Our meta-analysis showed that although CR does not reduce mortality, it is effective in reducing rehospitalization rates and improving exercise tolerance and quality of life, regardless of the intervention duration.

Exercise-based cardiac rehabilitation for adults with heart failure

BACKGROUND

People with heart failure experience substantial disease burden that includes low exercise tolerance, poor health-related quality of life (HRQoL), increased risk of mortality and hospital admission, and high healthcare costs. The previous 2018 Cochrane review reported that exercise-based cardiac rehabilitation (ExCR) compared to no exercise control shows improvement in HRQoL and hospital admission amongst people with heart failure, as well as possible reduction in mortality over the longer term, and that these reductions appear to be consistent across patient and programme characteristics. Limitations noted by the authors of this previous Cochrane review include the following: (1) most trials were undertaken in patients with heart failure with reduced (< 45%) ejection fraction (HFrEF), and women, older people, and those with heart failure with preserved (≥ 45%) ejection fraction (HFpEF) were under-represented; and (2) most trials were undertaken in a hospital or centre-based setting.

OBJECTIVES

To assess the effects of ExCR on mortality, hospital admission, and health-related quality of life of adults with heart failure.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO and Web of Science without language restriction on 13 December 2021. We also checked the bibliographies of included studies, identified relevant systematic reviews, and two clinical trials registers.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared ExCR interventions (either exercise only or exercise as part of a comprehensive cardiac rehabilitation) with a follow-up of six months or longer versus a no-exercise control (e.g. usual medical care). The study population comprised adults (≥ 18 years) with heart failure - either HFrEF or HFpEF.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were all-cause mortality, mortality due to heart failure, all-cause hospital admissions, heart failure-related hospital admissions, and HRQoL. Secondary outcomes were costs and cost-effectiveness. We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 60 trials (8728 participants) with a median of six months' follow-up. For this latest update, we identified 16 new trials (2945 new participants), in addition to the previously identified 44 trials (5783 existing participants). Although the existing evidence base predominantly includes patients with HFrEF, with New York Heart Association (NYHA) classes II and III receiving centre-based ExCR programmes, a growing body of trials includes patients with HFpEF with ExCR undertaken in a home-based setting. All included trials employed a usual care comparator with a formal no-exercise intervention as well as a wide range of active comparators, such as education, psychological intervention, or medical management. The overall risk of bias in the included trials was low or unclear, and we mostly downgraded the certainty of evidence of outcomes upon GRADE assessment. There was no evidence of a difference in the short term (up to 12 months' follow-up) in the pooled risk of all-cause mortality when comparing ExCR versus usual care (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.71 to 1.21; absolute effects 5.0% versus 5.8%; 34 trials, 36 comparisons, 3941 participants; low-certainty evidence). Only a few trials reported information on whether participants died due to heart failure. Participation in ExCR versus usual care likely reduced the risk of all-cause hospital admissions (RR 0.69, 95% CI 0.56 to 0.86; absolute effects 15.9% versus 23.8%; 23 trials, 24 comparisons, 2283 participants; moderate-certainty evidence) and heart failure-related hospital admissions (RR 0.82, 95% CI 0.49 to 1.35; absolute effects 5.6% versus 6.4%; 10 trials; 10 comparisons, 911 participants; moderate-certainty evidence) in the short term. Participation in ExCR likely improved short-term HRQoL as measured by the Minnesota Living with Heart Failure (MLWHF) questionnaire (lower scores indicate better HRQoL and a difference of 5 points or more indicates clinical importance; mean difference (MD) -7.39 points, 95% CI -10.30 to -4.77; 21 trials, 22 comparisons, 2699 participants; moderate-certainty evidence). When pooling HRQoL data measured by any questionnaire/scale, we found that ExCR may improve HRQoL in the short term, but the evidence is very uncertain (33 trials, 37 comparisons, 4769 participants; standardised mean difference (SMD) -0.52, 95% CI -0.70 to -0.34; very-low certainty evidence). ExCR effects appeared to be consistent across different models of ExCR delivery: centre- versus home-based, exercise dose, exercise only versus comprehensive programmes, and aerobic training alone versus aerobic plus resistance programmes.

AUTHORS' CONCLUSIONS

This updated Cochrane review provides additional randomised evidence (16 trials) to support the conclusions of the previous 2018 version of the review. Compared to no exercise control, whilst there was no evidence of a difference in all-cause mortality in people with heart failure, ExCR participation likely reduces the risk of all-cause hospital admissions and heart failure-related hospital admissions, and may result in important improvements in HRQoL. Importantly, this updated review provides additional evidence supporting the use of alternative modes of ExCR delivery, including home-based and digitally-supported programmes. Future ExCR trials need to focus on the recruitment of traditionally less represented heart failure patient groups including older patients, women, and those with HFpEF.

Which Components of The International Classification of Functioning, Disability and Health (ICF) are Covered by Cardiac Rehabilitation Assessment Tools among Individuals with Heart Failure?

BACKGROUND

The therapeutic assessment of functioning in cardiac rehabilitation from the perspective of the International Classification of Functioning, Disability and Health (ICF) can provide a biopsychosocial approach to health care. However, it is unclear which components are reflected in the instruments used for cardiac rehabilitation in individuals with heart failure (HF).

OBJECTIVES

To investigate which ICF components (body function, structures, activities, participation, environmental factors, and personal factors) are represented in the assessment instruments used in individuals with HF and to identify the most appropriate instrument to use based on the inclusion of these factors.

METHODS

Forty-four clinical trials included in an updated Cochrane systematic review that investigated the effects of exercise-based cardiac rehabilitation in patients with HF were reviewed. The instruments were analyzed to extract significant concepts linked to the ICF codes.

RESULTS

A total of 12 outcomes and 40 instruments were identified. The concepts were linked to 2466 codes in the following ICF components: body functions (41.8%), activities (29.7%), participation (8.4%), environmental factors (3.8%), personal factors (1.3%), and body structures (1.0%); other concepts (13.9%) were classified as not covered by ICF. None of the instruments presented concepts linked to all ICF components. The Minnesota Living with Heart Failure Questionnaire (MLHFQ), however, demonstrated comprehensive coverage of the ICF components, with the exception of body structure.

CONCLUSIONS

Body function was the most frequently detected ICF component. Individual instruments did not provide a comprehensive perspective on the functioning level of individuals with HF. The MLHFQ provided the greatest coverage of ICF components.

Effective Strategies for Physical Activity Adherence in Heart Failure Patients: An Umbrella Review

Background

Despite the importance of physical activity in heart failure treatment, physical activity adherence in heart failure patients is low. The purpose of this umbrella review was to obtain the best strategies for enhancing physical activity adherence among HF patients.

Methods

Databases were investigated from 2010 to Jan 2022. The full text of the papers was investigated in terms of inclusion and exclusion criteria. Eventually, out of 74 relevant papers, 7-review study with 20977 patients were eligible and included in the study.

Results

Five key effective approaches were identified in two subsets for enhancing physical activity adherence as follows: 1) exercise-based approaches including 1.1) Exergames, whereby the extent of adherence to exergames was between 84 and 98%. 1.2) Tele-rehabilitation with 70%-100% adherence the intervention groups 1.3) Tai chi and Qigong practices (TQPs), whereby the exercise adherence in TQP groups was 67-100%, 2. Theoretical-behavioral approaches 2.1) approaches based on behavioral and psychological theories, which were a combination of an exercise program alongside a behavior modification intervention, 2.2) Self-efficacy.

Conclusion

Approaches that are based on exercise alongside behavioral and theoretical interventions could enhance physical activity adherence among HF patients. It is suggested to evaluate mix methods of exercise-based approaches and theoretical-behavioral approaches mentioned in this study in future clinical trial studies. Use of capacity of TR programs improve to physical activity adherence should receive more attention.

Traditional Baduanjin exercise through the eyes of patients with chronic heart failure: A qualitative content analysis study

Objective

Baduanjin (eight silken movements) is a traditional Chinese exercise that can be used as cardiac rehabilitation therapy for patients with chronic heart failure (CHF) especially when other forms of rehabilitation are scarce or unaffordable. This study explores the experiences of Chinese patients with CHF who undertook Baduanjin exercise at home as part of a pilot trial in Guangzhou, China.

Methods

We conducted seven qualitative interviews with participants who had participated in the intervention arm of a pilot randomized controlled trial (RCT) (n = 8). For data collection, we used a semi-structured interview guide with both open-ended, and follow-up questions. We audio recorded the interviews, transcribed them verbatim, and then analyzed them with content analysis.

Results

Participants' experiences of doing Baduanjin were classified into three categories: (1) improving practice (2) factors facilitating good exercise adherence, and (3) feeling good. Participants reported that the exercises were easy but that the correct Baduanjin execution and coordination between the mind, movements, and breathing were only achievable through practice. In addition, the training benefits which they perceived were the predominant motivation for patients to keep practicing. Finally, trust in Baduanjin, personal attitudes toward health, flexibility in practice times, as well as social support helped the participants to achieve good adherence to home-based training.

Conclusion

This study's findings indicate that Baduanjin could be a cardiac rehabilitation exercise modality for patients with CHF in China, especially in a home-based setting.

The Role of Exercise Self-Efficacy in Exercise Participation Among Women With Persistent Fatigue After Breast Cancer: A Mixed-Methods Study

OBJECTIVE

Survivors of breast cancer with persistent cancer-related fatigue (CRF) report less exercise participation compared with survivors of breast cancer without CRF. Although CRF predicts other domains of self-efficacy among survivors, the effect of CRF on exercise self-efficacy (ESE)-an important predictor of exercise participation-has not been quantified. This study examined the relationship between CRF, ESE, and exercise participation and explored the lived experience of engaging in exercise among survivors of breast cancer with persistent CRF.

METHODS

Fifty-eight survivors of breast cancer (3.7 [SD = 2.4] years after primary treatment) self-reported CRF, ESE, and exercise participation (hours of moderate-intensity exercise per week). Regression and mediation analyses were conducted. Survivors who reported clinically significant CRF and weekly exercise were purposively sampled for 1-on-1 interviews (N = 11). Thematic analysis was performed across participants and within higher versus lower ESE subsets.

RESULTS

Greater CRF predicted lower ESE (β = -0.32) and less exercise participation (β = -0.08). ESE mediated the relationship between CRF and exercise participation (β = -0.05, 95% CI = -0.09 to -0.02). Qualitative data showed that survivors of breast cancer with higher ESE perceived exercise as a strategy to manage fatigue, described self-motivation and commitment to exercise, and had multiple sources of support. In contrast, survivors with lower ESE described less initiative to manage fatigue through exercise, greater difficulty staying committed to exercise, and less support.

CONCLUSIONS

Survivors of breast cancer with persistent CRF may experience decreased ESE, which negatively influences exercise participation. Clinicians should screen for or discuss confidence as it relates to exercise and consider tailoring standardized exercise recommendations for this population to optimize ESE. This may facilitate more sustainable exercise participation and improve outcomes.

IMPACT

This study highlights the behavioral underpinnings of CRF as a barrier to exercise. Individualized exercise tailored to optimize ESE may facilitate sustainable exercise participation among survivors of breast cancer with CRF. Strategies for clinicians to address ESE are described and future research is suggested.

LAY SUMMARY

Women with fatigue after breast cancer treatment may have lower confidence about their ability to engage in exercise. Individually tailoring exercise to build confidence as it relates to exercise may result in more consistent exercise and better health-related outcomes.

Effects of exercise-based cardiac rehabilitation delivery modes on exercise capacity and health-related quality of life in heart failure: a systematic review and network meta-analysis

Background

This review aimed to compare the relative effectiveness of different exercise-based cardiac rehabilitation (ExCR) delivery modes (centre-based, home-based, hybrid and technology-enabled ExCR) on key heart failure (HF) outcomes: exercise capacity, health-related quality of life (HRQoL), HF-related hospitalisation and HF-related mortality.

Methods and results

Randomised controlled trials (RCTs) published through 20 June 2021 were identified from six databases, and reference lists of included studies. Risk of bias and certainty of evidence were evaluated using the Cochrane tool and Grading of Recommendations Assessment, Development and Evaluation, respectively. Bayesian network meta-analysis was performed using R. Continuous and binary outcomes are reported as mean differences (MD) and ORs, respectively, with 95% credible intervals (95% CrI). One-hundred and thirty-nine RCTs (n=18 670) were included in the analysis. Network meta-analysis demonstrated improvements in VO₂peak following centre-based (MD (95% CrI)=3.10 (2.56 to 3.65) mL/kg/min), home-based (MD=2.69 (1.67 to 3.70) mL/kg/min) and technology-enabled ExCR (MD=1.76 (0.27 to 3.26) mL/kg/min). Similarly, 6 min walk distance was improved following hybrid (MD=84.78 (31.64 to 138.32) m), centre-based (MD=50.35 (30.15 to 70.56) m) and home-based ExCR (MD=36.77 (12.47 to 61.29) m). Incremental shuttle walk distance did not improve following any ExCR delivery modes. Minnesota living with HF questionnaire improved after centre-based (MD=−10.38 (−14.15 to –6.46)) and home-based ExCR (MD=−8.80 (−13.62 to –4.07)). Kansas City Cardiomyopathy Questionnaire was improved following home-based ExCR (MD=20.61 (4.61 to 36.47)), and Short Form Survey 36 mental component after centre-based ExCR (MD=3.64 (0.30 to 6.14)). HF-related hospitalisation and mortality risks reduced only after centre-based ExCR (OR=0.41 (0.17 to 0.76) and OR=0.42 (0.16 to 0.90), respectively). Mean age of study participants was only associated with changes in VO₂peak.

Conclusion

ExCR programmes have broader benefits for people with HF and since different delivery modes were comparably effective for improving exercise capacity and HRQoL, the selection of delivery modes should be tailored to individuals’ preferences.

The Effects of Exercise-Based Interventions on Fluid Overload Symptoms in Patients with Heart Failure: A Systematic Review and Meta-Analysis

Patients with heart failure are subjected to a substantial burden related to fluid overload symptoms. Exercise can help the lymphatic system function more effectively to prevent fluid build-up in tissues and interstitium, thus potentially mitigating the symptoms due to fluid overload. The objective of this systematic review was to examine the effects of exercise-based interventions on fluid overload symptoms among patients with heart failure. MEDLINE, Embase, Cochrane Library, and CINAHL databases were systematically searched for relevant studies published from inception to August 2021. We included randomized controlled trials that compared exercise-based interventions of different modalities and usual medical care for adult patients with heart failure and reported the effects of interventions on any symptoms related to fluid overload. A random-effects meta-analysis was used to estimate the effectiveness, and a subgroup analysis and univariate meta-regression analysis were used to explore heterogeneity. Seventeen studies covering 1086 participants were included. We found robust evidence indicating the positive effect of exercises in dyspnea relief (SMD = -0.48; 95%CI [-0.76, -0.19]; p = 0.001); the intervention length also influenced the treatment effect (β = 0.033; 95%CI [0.003, 0.063]; p = 0.04). Initial evidence from existing limited research showed that exercise-based intervention had positive effect to alleviate edema, yet more studies are needed to verify the effect. In contrast, the exercise-based interventions did not improve fatigue compared with usual care (SMD = -0.27; 95%CI [-0.61, 0.06]; p = 0.11). Findings regarding the effects of exercises on bodily pain, gastro-intestinal symptoms, and peripheral circulatory symptoms were inconclusive due to limited available studies. In conclusion, exercise-based interventions can be considered as an effective nonpharmacological therapy for patients with heart failure to promote lymph flow and manage fluid overload symptoms. Exercise-based interventions seem to have very limited effect on fatigue. More research should investigate the mechanism of fatigue related to heart failure. Future studies with high methodological quality and comprehensive assessment of symptoms and objective measure of fluid overload are warranted.

The HEART Camp Exercise Intervention Improves Exercise Adherence, Physical Function, and Patient-Reported Outcomes in Adults With Preserved Ejection Fraction Heart Failure

BACKGROUND

Despite exercise being one of few strategies to improve outcomes for individuals with heart failure with preserved ejection fraction (HFpEF), exercise clinical trials in HFpEF are plagued by poor interventional adherence. Over the last 2 decades, our research team has developed, tested, and refined Heart failure Exercise And Resistance Training (HEART) Camp, a multicomponent behavioral intervention to promote adherence to exercise in HF. We evaluated the effects of this intervention designed to promote adherence to exercise in HF focusing on subgroups of participants with HFpEF and heart failure with reduced ejection fraction (HFrEF).

METHODS AND RESULTS

This randomized controlled trial included 204 adults with stable, chronic HF. Of those enrolled, 59 had HFpEF and 145 had HFrEF. We tested adherence to exercise (defined as ≥120 minutes of moderate-intensity [40%-80% of heart rate reserve] exercise per week validated with a heart rate monitor) at 6, 12, and 18 months. We also tested intervention effects on symptoms (Patient-Reported Outcomes Measurement Information System-29 and dyspnea-fatigue index), HF-related health status (Kansas City Cardiomyopathy Questionnaire), and physical function (6-minute walk test). Participants with HFpEF (n = 59) were a mean of 64.6 ± 9.3 years old, 54% male, and 46% non-White with a mean ejection fraction of 55 ± 6%. Participants with HFpEF in the HEART Camp intervention group had significantly greater adherence compared with enhanced usual care at both 12 (43% vs 14%, phi = 0.32, medium effect) and 18 months (56% vs 0%, phi = 0.67, large effect). HEART Camp significantly improved walking distance on the 6-minute walk test (η2 = 0.13, large effect) and the Kansas City Cardiomyopathy Questionnaire overall (η2 = 0.09, medium effect), clinical summary (η2 = 0.16, large effect), and total symptom (η2 = 0.14, large effect) scores. In the HFrEF subgroup, only patient-reported anxiety improved significantly in the intervention group.

CONCLUSIONS

A multicomponent, behavioral intervention is associated with improvements in long-term adherence to exercise, physical function, and patient-reported outcomes in adults with HFpEF and anxiety in HFrEF. Our results provide a strong rationale for a large HFpEF clinical trial to validate these findings and examine interventional mechanisms and delivery modes that may further promote adherence and improve clinical outcomes in this population.

CLINICAL TRIAL REGISTRATION

URL: https://clinicaltrials.gov/. Unique identifier: NCT01658670.

Negative Attitudes, Self-efficacy, and Relapse Management Mediate Long-Term Adherence to Exercise in Patients With Heart Failure

BACKGROUND

Exercise is safe and provides considerable benefits for patients with heart failure (HF) including improved function, quality of life, and symptoms. However, patients with HF have difficulty initiating and adhering to an exercise regimen. To improve adherence, our team developed Heart Failure Exercise and Resistance Training (HEART) Camp, a multicomponent, theory-driven intervention that was efficacious in a randomized controlled trial of long-term adherence to exercise in patients with HF. Identifying active components of efficacious interventions is a priority.

PURPOSE

The purpose of this study is to use mediation analysis to determine which interventional components accounted for long-term adherence to exercise in patients with HF.

METHODS

This study included 204 patients with HF enrolled in a randomized controlled trial. Instruments measuring interventional components were completed at baseline, 6, 12, and 18 months. Hierarchical linear models generated slope estimates to be used as predictors in logistic regression models. Significant variables were tested for indirect effects using path analyses with 1,000 bootstrapped estimates.

RESULTS

Significant mediation effects were observed for the interventional components of negative attitudes (β NA = 0.368, s.e. = 0.062, p < .001), self-efficacy (β SE = 0.190, s.e. = 0.047, p < .001), and relapse management (β RM = 0.243, s.e. = 0.076, p = .001).

CONCLUSIONS

These findings highlight improving attitudes, self-efficacy, and managing relapse as key interventional components to improve long-term adherence to exercise in patients with HF. Future interventions targeting adherence to exercise in patients with HF and other chronic illnesses should consider the incorporation of these active components.

A systematic review of rehabilitation in chronic heart failure: evaluating the reporting of exercise interventions

A large body of research supports the use of exercise to improve symptoms, quality of life, and physical function in patients with chronic heart failure. Previous reviews have focused on reporting outcomes of exercise interventions such as cardiorespiratory fitness. However, none have critically examined exercise prescription. The aim of this review was to evaluate the reporting and application of exercise principles in randomised control trials of exercise training in patients with chronic heart failure. A systematic review of exercise intervention RCTs in patients with CHF, using the Consensus on Exercise Reporting Template (CERT), was undertaken. The Ovid Medline/PubMed, Embase, Scopus/Web of Science, and Cochrane Library and Health Technology Assessment Databases were searched from 2000 to June 2020. Prospective RCTs in which patients with CHF were randomized to a structured exercise programme were included. No limits were placed on the type or duration of exercise structured exercise programme or type of CHF (i.e. preserved or reduced ejection fraction). We included 143 studies, comprising of 181 different exercise interventions. The mean CERT score was 10 out of 19, with no study achieving a score of 19. Primarily, details were missing regarding motivational strategies, home-based exercise components, and adherence/fidelity to the intervention. Exercise intensity was the most common principle of exercise prescription missing from intervention reporting. There was no improvement in the reporting of exercise interventions with time (R²  = 0.003). Most RCTs of exercise training in CHF are reported with insufficient detail to allow for replication, limiting the translation of evidence to clinical practice. We encourage authors to provide adequate details when reporting future interventions. Where journal word counts are restrictive, we recommend using supplementary material or publishing trial protocols prior to beginning the study.

People living with dementia and their family carers' adherence to home-based Tai Chi practice

Objectives

The aim of this study was to understand what influenced people living with dementia and their family carers’ adherence to the home-based component of a Tai Chi exercise intervention.

Method

Dyads, of people living with dementia and their family carers, who participated in the intervention arm of the Tai Chi for people living with dementia trial, were invited to join weekly Tai Chi classes for 20 weeks and practice at home. Semi-structured dyadic home interviews were conducted on average after 16 weeks of classes. The views of 15 dyads with a range of home practice adherence were sought in semi-structured interviews. The interviews were analysed using an inductive thematic approach.

Results

Most participants found time to practise Tai Chi at home and practised for 18 hours on average. Amongst the barriers to adherence were participants’ competing commitments and a booklet not sufficiently conveying the Tai Chi movements. Hence, a video or DVD was requested by participants. Facilitators of their adherence to the home-based component of the intervention were their enjoyment of the practice and the development of a habit, which was supported by their commitment to the study and their willingness to benefit from Tai Chi.

Conclusion

Enjoyment and perceived benefits had a great impact on participants living with dementia and their carers’ adherence to home-based Tai Chi practice. However, difficulties to perceive the Tai Chi movements through images might be hindering sustained participation. Hence, alternative aids such as videos and DVDs should be explored to facilitate adherence.

An evidence-based structured one-year programme to sustain physical activity in patients with heart failure in primary care: A non-randomized longitudinal feasibility study

Aim

The primary objective of this non-randomized feasibility study was to test a 1-year model programme for sustaining/increasing patients' motivation to perform daily physical activity.

Design

Non-randomized longitudinal feasibility study with a one-group repeated measures design.

Methods

The study took place at a primary care centre in mid-Sweden in 2017-2018. The model programme included individual and group-based support, individualized physical activity prescriptions, a wrist-worn activity tracker and an activity diary. The main outcomes were the participants' perceptions of programme feasibility and scores on the Exercise Self-Efficacy Scale.

Results

Seven patients were recruited. Six patients completed the programme that was perceived to imply learning, motivation and support. Compared with baseline, the median score of the Exercise Self-Efficacy Scale improved 3 months after participants completed the programme.

Confirming a beneficial effect of the six-minute walk test on exercise confidence in patients with heart failure

Background:

Low confidence to exercise is a barrier to engaging in exercise in heart failure patients. Participating in low to moderate intensity exercise, such as the six-minute walk test, may increase exercise confidence.

Aim:

To compare the effects of a six-minute walk test with an educational control condition on exercise confidence in heart failure patients.

Methods:

This was a prospective, quasi-experimental design whereby consecutive adult patients attending an out-patient heart failure clinic completed the Exercise Confidence Scale prior to and following involvement in the six-minute walk test or an educational control condition.

Results:

Using a matched pairs, mixed model design ( n=60; 87% male; Mage=58.87±13.16), we identified a significantly greater improvement in Total exercise confidence ( F(1,54)=4.63, p=0.036, partial η2=0.079) and Running confidence ( F(1,57)=4.21, p=0. 045, partial η2=0.069) following the six-minute walk test compared to the educational control condition. These benefits were also observed after adjustment for age, gender, functional class and depression.

Conclusion:

Heart failure patients who completed a six-minute walk test reported greater improvement in exercise confidence than those who read an educational booklet for 10 min. The findings suggest that the six-minute walk test may be used as a clinical tool to improve exercise confidence. Future research should test these results under randomized conditions and examine whether improvements in exercise confidence translate to greater engagement in exercise behavior.

The effect of an educational program based on Roy's adaptation model on the quality of life of patients suffering from heart failure: A clinical trial study

AIM

Heart failure is a progressive, debilitating disease with exacerbated physical and psychological symptoms that reduces the quality of life of patients. Nursing intervention based on nursing theories could help in the adaptation of patients to the disease and improving quality of life. The aim of this study was to determine the effect of an educational program based on Roy's adaptation model on the quality of life of patients with heart failure.

METHODS AND MATERIAL

In this randomized controlled trial, 76 patients with heart failure were allocated to either the intervention or control group through a blocked randomization method. The data were collected between May and October 2017. The intervention group received oral and written educational programs for 4 weeks. Minnesota quality-of-life questionnaire and Roy's adaptation model-based evaluation form was completed at the beginning of the trial, and 1 month after the completion of the study.

RESULTS

Intervention patients showed statistically significantly improved scores on the physiologic, role function, independence-interdependence dimensions and the total score of Roy's adaptation model over time compared with control patients (p < .05). The mean score of all of the three quality-of-life dimensions and total score of quality of life increased significantly (p < .05).

CONCLUSION

The study results help nursing staff detect the stimuli and the behaviors of patients with heart failure. Roy's adaptation model can be used as a standard practice to increase adaptation to the disease and improving quality of life.

Incorporating intervention fidelity components into randomized controlled trials promoting exercise adherence in heart failure patients

Intervention fidelity (IF) in behavioral interventions is complicated by their dynamic and interactive nature. Translation of the outcomes to practice may be diminished by lack of fidelity. The purpose of this paper is to describe a systematic, evidence-based IF approach in a complex, multicomponent behavioral change study. The National Institutes of Health-funded randomized controlled trial was designed to evaluate the effect of an adherence to exercise intervention. Two hundred forty-six heart failure patients from two sites were enrolled. This description of the study-specific standardized protocol, the data collection methods used, findings from the plan, and the discussion of the successes and challenges contributes to the advancement of IF implementation science.

Exercise-based cardiac rehabilitation for adults with heart failure

BACKGROUND

Chronic heart failure (HF) is a growing global health challenge. People with HF experience substantial burden that includes low exercise tolerance, poor health-related quality of life (HRQoL), increased risk of mortality and hospital admission, and high healthcare costs. The previous (2014) Cochrane systematic review reported that exercise-based cardiac rehabilitation (CR) compared to no exercise control shows improvement in HRQoL and hospital admission among people with HF, as well as possible reduction in mortality over the longer term, and that these reductions appear to be consistent across patient and programme characteristics. Limitations noted by the authors of this previous Cochrane Review include the following: (1) most trials were undertaken in patients with HF with reduced (< 45%) ejection fraction (HFrEF), and women, older people, and those with preserved (≥ 45%) ejection fraction HF (HFpEF) were under-represented; and (2) most trials were undertaken in the hospital/centre-based setting.

OBJECTIVES

To determine the effects of exercise-based cardiac rehabilitation on mortality, hospital admission, and health-related quality of life of people with heart failure.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and three other databases on 29 January 2018. We also checked the bibliographies of systematic reviews and two trial registers.

SELECTION CRITERIA

We included randomised controlled trials that compared exercise-based CR interventions with six months' or longer follow-up versus a no exercise control that could include usual medical care. The study population comprised adults (> 18 years) with evidence of HF - either HFrEF or HFpEF.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all identified references and rejected those that were clearly ineligible for inclusion in the review. We obtained full papers of potentially relevant trials. Two review authors independently extracted data from the included trials, assessed their risk of bias, and performed GRADE analyses.

MAIN RESULTS

We included 44 trials (5783 participants with HF) with a median of six months' follow-up. For this latest update, we identified 11 new trials (N = 1040), in addition to the previously identified 33 trials. Although the evidence base includes predominantly patients with HFrEF with New York Heart Association classes II and III receiving centre-based exercise-based CR programmes, a growing body of studies include patients with HFpEF and are undertaken in a home-based setting. All included studies included a no formal exercise training intervention comparator. However, a wide range of comparators were seen across studies that included active intervention (i.e. education, psychological intervention) or usual medical care alone. The overall risk of bias of included trials was low or unclear, and we downgraded results using the GRADE tool for all but one outcome.Cardiac rehabilitation may make little or no difference in all-cause mortality over the short term (≤ one year of follow-up) (27 trials, 28 comparisons (2596 participants): intervention 67/1302 (5.1%) vs control 75/1294 (5.8%); risk ratio (RR) 0.89, 95% confidence interval (CI) 0.66 to 1.21; low-quality GRADE evidence) but may improve all-cause mortality in the long term (> 12 months follow up) (6 trials/comparisons (2845 participants): intervention 244/1418 (17.2%) vs control 280/1427 (19.6%) events): RR 0.88, 95% CI 0.75 to 1.02; high-quality evidence). Researchers provided no data on deaths due to HF. CR probably reduces overall hospital admissions in the short term (up to one year of follow-up) (21 trials, 21 comparisons (2182 participants): (intervention 180/1093 (16.5%) vs control 258/1089 (23.7%); RR 0.70, 95% CI 0.60 to 0.83; moderate-quality evidence, number needed to treat: 14) and may reduce HF-specific hospitalisation (14 trials, 15 comparisons (1114 participants): (intervention 40/562 (7.1%) vs control 61/552 (11.1%) RR 0.59, 95% CI 0.42 to 0.84; low-quality evidence, number needed to treat: 25). After CR, a clinically important improvement in short-term disease-specific health-related quality of life may be evident (Minnesota Living With Heart Failure questionnaire - 17 trials, 18 comparisons (1995 participants): mean difference (MD) -7.11 points, 95% CI -10.49 to -3.73; low-quality evidence). Pooling across all studies, regardless of the HRQoL measure used, shows there may be clinically important improvement with exercise (26 trials, 29 comparisons (3833 participants); standardised mean difference (SMD) -0.60, 95% CI -0.82 to -0.39; I² = 87%; Chi² = 215.03; low-quality evidence). ExCR effects appeared to be consistent different models of ExCR delivery: centre vs. home-based, exercise dose, exercise only vs. comprehensive programmes, and aerobic training alone vs aerobic plus resistance programmes.

AUTHORS' CONCLUSIONS

This updated Cochrane Review provides additional randomised evidence (11 trials) to support the conclusions of the previous version (2014) of this Cochane Review. Compared to no exercise control, CR appears to have no impact on mortality in the short term (< 12 months' follow-up). Low- to moderate-quality evidence shows that CR probably reduces the risk of all-cause hospital admissions and may reduce HF-specific hospital admissions in the short term (up to 12 months). CR may confer a clinically important improvement in health-related quality of life, although we remain uncertain about this because the evidence is of low quality. Future ExCR trials need to continue to consider the recruitment of traditionally less represented HF patient groups including older, female, and HFpEF patients, and alternative CR delivery settings including home- and using technology-based programmes.

Effects of the HEART Camp Trial on Adherence to Exercise in Patients With Heart Failure

BACKGROUND

Few exercise training studies in patients with heart failure (HF) report adherence to guideline-recommended 150 minutes of moderate-intensity exercise per week, and no studies have focused on a primary outcome of adherence.

METHODS AND RESULTS

This randomized controlled trial evaluated the effect of a multicomponent intervention, Heart Failure Exercise and Resistance Training (HEART) Camp, on adherence to exercise (after 6, 12, and 18 months) compared with an enhanced usual care (EUC) group. Patients (n = 204) were 55.4% male, overall average age was 60.4 years, and 47.5% were nonwhite. The HEART Camp group had significantly greater adherence at 12 (42%) and 18 (35%) months compared with the EUC group (28% and 19%, respectively). No significant difference (P > .05) was found at 6 months. The treatment effect did not differ based on patient's age, race, gender, marital status, type of HF (preserved or reduced ejection fraction) or New York Heart Association functional class. Left ventricular ejection fraction (LVEF) significantly moderated the treatment effect, with greater adherence at higher LVEF.

CONCLUSIONS

The multicomponent HEART Camp intervention showed efficacy with significant effects at 12 months and 18 months. Adherence levels remained modest, indicating a need for additional research to address methods and strategies to promote adherence to exercise in patients with HF.

Effect of an exercise-based cardiac rehabilitation program "Baduanjin Eight-Silken-Movements with self-efficacy building" for heart failure (BESMILE-HF study): study protocol for a randomized controlled trial

BACKGROUND

Exercise-based cardiac rehabilitation is a beneficial therapy for patients with chronic heart failure. The delivery of exercise-based cardiac rehabilitation should adopt an evidence-based approach, as well as be culturally appropriate and sensitive to individual needs and preferences. The Baduanjin Eight-Silken-Movements with Self-efficacy Building for Heart Failure (BESMILE-HF) program is the first to apply a traditional Chinese exercise, Baduanjin, as the core component in an exercise-based cardiac rehabilitation program. This trial aims to assess the efficacy, safety, and acceptability of the addition of the BESMILE-HF program to usual medications for patients with chronic heart failure.

METHODS/DESIGN

The BESMILE-HF study is a mixed-design study. It includes a two-group, parallel, randomized controlled trial with 200 chronic heart failure patients, as well as a qualitative component. Patients will be randomized into either an intervention group receiving the 12-week BESMILE-HF program plus usual medications, or a control group receiving only usual medications. The primary outcomes are peak oxygen consumption assessed using a cardiopulmonary exercise test, and disease-specific quality of life using the Minnesota Living with Heart Failure Questionnaire. The secondary outcomes are: exercise performance, exercise self-efficacy, general quality of life, dyspnea and fatigue, depression, cardiac function, prognostic and inflammatory indicator levels, hospitalization, use of medications, and major adverse cardiac events. Assessments will be carried out at baseline, and at the 4th week, 8th week, and 12th week. The qualitative component will include a semi-structure interview describing patients' experiences with the intervention.

DISCUSSION

This study can provide evidence for how to deliver a contextually adapted exercise-based cardiac rehabilitation program with the potential to be scaled up throughout China.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03180320 . Registered on 2 June 2017.

A model to increase rehabilitation adherence to home exercise programmes in patients with varying levels of self-efficacy

Patient adherence to rehabilitation programmes is frequently low - particularly adherence to home exercise programmes. Home exercise programmes have been identified as complementary to clinic-based physical therapy in an orthopaedic setting. Barriers to patient adherence have previously been identified within the literature. Low self-efficacy is a barrier to adherence that clinicians have the ability to have an impact on and improve. The theory of self-efficacy is defined as a person's confidence in their ability to perform a task. This theory examines the ability of a person to change through exerting control over inner processes of goal setting, self-monitoring, feedback, problem solving and self-evaluation. If clinicians are able to identify patients with low self-efficacy prior to the prescription of a home exercise programme, adjustments to individualized care can be implemented. Individualized care based on improving self-efficacy for home exercise programmes may improve patient adherence to these programmes. The purpose of this article was to use the theory of self-efficacy to direct clinicians in providing individualized programmes to patients with varying levels of self-efficacy.

Nonpharmacological interventions to improve quality of life in heart failure: an integrative review

Objective:

to identify articles that assessed the effectiveness or efficacy of nonpharmacological interventions to improve quality of life of people with heart failure in the literature.

Method:

an integrative literature review was performed in Lilacs, MedLine and SciELO databases, including randomized or nonrandomized clinical trials and quasi-experimental studies published between 2003 and 2014, in Portuguese, English or Spanish.

Results:

twenty-three studies were included. The categories of nonpharmacological interventions that improved quality of life of people with heart failure were: Remote health monitoring, Instructions on health practices, Physical activity follow-up and Traditional Chinese Medicine practices.

Conclusion:

these results can guide the selection of interventions to be implemented by health professionals that treat people with heart failure. Future systematic reviews with meta-analyses are needed in order to identify the most effective interventions for improving these individuals' quality of life.

Heart Failure and Exercise: A Narrative Review of the Role of Self-Efficacy

Chronic heart failure (CHF) is a common, debilitating condition associated with significant health and economic burden. CHF management is multidisciplinary, however, achieving better health relies on a collaborative effort and patient engagement in self-care. Despite the importance of self-care in CHF, many patients have poor adherence to their medical and lifestyle regimens, in particular with regards to engaging in physical exercise. The patient's confidence in their ability, otherwise known as self-efficacy, is an important determinant of CHF health outcomes, most likely due to its effect on the uptake of CHF self-care activities especially exercise initiation and maintenance. Self-efficacy is responsive to experience such as exercise training, however the critical components of exercise interventions to improve self-efficacy have yet to be determined. This narrative review provides an overview of the role of self-efficacy in exercise adherence in CHF.

Depression and self-care maintenance in patients with heart failure: A moderated mediation model of self-care confidence and resilience

BACKGROUND

Despite the recognition of the negative effects of depressive symptoms on self-care confidence and self-care maintenance in patients with heart failure, little is known about the moderating role of resilience underlying these relations.

AIMS

To explore whether depressive symptoms affect self-care maintenance through self-care confidence and whether this mediating process was moderated by resilience.

METHODS

The sample comprised 201 community-dwelling and medically stable patients with echocardiographically documented heart failure. A moderated mediation model was conducted to test whether self-care confidence mediated the association between depressive symptoms and self-care maintenance, and whether resilience moderated the direct and indirect effects of depressive symptoms after adjustment for covariates.

RESULTS

Depressive symptoms reduced self-care maintenance indirectly by decreasing self-care confidence (indirect effect: -0.22, 95% confidence interval: -0.36, -0.11), and this pathway was only significant for patients with moderate and high levels and not with low levels of resilience. Resilience also moderated the direct effects of depressive symptoms on self-care maintenance such that the negative association between depressive symptoms and self-care maintenance was reversed by the existence of high resilience.

CONCLUSIONS

Resilience moderated the direct and indirect effects of depressive symptoms through self-care confidence on self-care maintenance in heart failure patients. Efforts to improve self-care maintenance by targeting depressive symptoms may be more effective when considering self-care confidence in patients with moderate to high levels of resilience.

Effect of short-term exercise intervention on cardiovascular functions and quality of life of chronic heart failure patients: A meta-analysis

OBJECTIVE

The purpose of this study was to comprehensively evaluate the effect of short-term exercise intervention on the cardiovascular functions and quality of life (QoL) of patients with chronic heart failure (CHF).

METHODS

This meta-analysis was analyzed using RevMan5.3 and Stata 13.0. The parameters of cardiovascular functions and QoL were assessed. Weighted mean differences and their corresponding 95% confidence intervals (CIs) were computed for continuous variables.

RESULTS

Data from 2533 CHF patients enrolled in 28 published studies of randomized controlled trials (RCTs) were collated. There were significant differences in VO2 max prior to and after exercise intervention in CHF patients who are 50-55 years old (5 RCTs; 95% CI, -4.86 to -2.29; I2 = 50.5%), 60-65 years old (10 RCTs; 95% CI, -2.66 to -2.04; I2 = 0%), and 69-75 years old (5 RCTs; 95% CI, -1.88 to -0.34; I2 = 38.5%). VO2 max was significantly increased by aerobic exercise (9 RCTs; 95% CI, -3.45 to -1.92; I2 = 37.7%) and combined aerobic resistance exercise (4 RCTs; 95% CI, -4.41 to -0.26; I2 = 76.6%). There were significant differences in cardiac output (n = 303; 95% CI, -0.25 to -0.02; I2 = 12%) and QoL (n = 299; 95% CI, 3.19 to 9.70; I2 = 17%) prior to and after short-term exercise.

CONCLUSION

Aerobic exercise and aerobic with resistance exercise can significantly improve the aerobic capacity of CHF patients, whereas resistance exercise cannot. The improvement in aerobic capacity caused by aerobic exercise and aerobic with resistance exercise decreases with age. Systolic blood pressure and ventricle structures and functions of CHF patients show no significant changes after the short-term exercise intervention.

Assessment of functional capacity and sleep quality of patients with chronic heart failure

Background:

Adequate sleep improves physical and mental alertness. However, there is a dearth of empirical data on functional capacity (FC) and sleep quality (SpQ) in patients with chronic heart failure (CHF).

Objective:

This study investigated the relationship between FC and SpQ of patients with CHF and apparently healthy controls (HCs).

Methods:

This case-control study recruited 50 patients with CHF whose left ventricular ejection fraction (LVEF) was <40%, attending cardiac clinics of selected government hospitals in Osun State. Furthermore, 50 age- and sex-matched healthy individuals were recruited as controls. Socio-demographic characteristics and cardiovascular parameters were assessed. The FC (VO₂ max) and SpQ were assessed using the 6-minute walk test (6-MWT) and Pittsburgh Sleep Quality Index (PSQI), respectively. Data were analysed using descriptive and inferential statistics. Alpha level was set at p < 0.05.

Results:

Patients had a significantly lower FC and poorer SpQ than HCs, 4.6 ± 0.5 versus 11.3 ± 1.6 mL/kg/min (t = −3.452; p = 0.001) and 8.74 ± 1.6 versus 3.8 ± 1.3 (t = −5.371; p = 0.001), respectively. HCs were about five times more likely to walk longer distance [odds ratio (OR), 4.8; confidence interval (CI), 2.0–11.1] and had a better heart rate (OR, 2.8; CI, 1.4–5.3) than patients. SpQ had a significant negative correlation with FC of patients (r = −0.362; p = 0.001) but a significant positive correlation with HCs (r = 0.481; p = 0.041). Furthermore, there were significant correlations between FC and body mass index in both groups (CHF: r = 0.247, p = 0.022; HCs: r = 0.321, p = 0.040).

Conclusion:

Patients with heart failure demonstrated lower functional capacity and poorer sleep quality.

Self-care confidence may be more important than cognition to influence self-care behaviors in adults with heart failure: Testing a mediation model

BACKGROUND

Cognitive impairment can reduce the self-care abilities of heart failure patients. Theory and preliminary evidence suggest that self-care confidence may mediate the relationship between cognition and self-care, but further study is needed to validate this finding.

OBJECTIVES

The aim of this study was to test the mediating role of self-care confidence between specific cognitive domains and heart failure self-care.

DESIGN

Secondary analysis of data from a descriptive study.

SETTINGS

Three out-patient sites in Pennsylvania and Delaware, USA.

PARTICIPANTS

A sample of 280 adults with chronic heart failure, 62 years old on average and mostly male (64.3%).

METHODS

Data on heart failure self-care and self-care confidence were collected with the Self-Care of Heart Failure Index 6.2. Data on cognition were collected by trained research assistants using a neuropsychological test battery measuring simple and complex attention, processing speed, working memory, and short-term memory. Sociodemographic data were collected by self-report. Clinical information was abstracted from the medical record. Mediation analysis was performed with structural equation modeling and indirect effects were evaluated with bootstrapping.

RESULTS

Most participants had at least 1 impaired cognitive domain. In mediation models, self-care confidence consistently influenced self-care and totally mediated the relationship between simple attention and self-care and between working memory and self-care (comparative fit index range: .929-.968; root mean squared error of approximation range: .032-.052). Except for short-term memory, which had a direct effect on self-care maintenance, the other cognitive domains were unrelated to self-care.

CONCLUSIONS

Self-care confidence appears to be an important factor influencing heart failure self-care even in patients with impaired cognition. As few studies have successfully improved cognition, interventions addressing confidence should be considered as a way to improve self-care in this population.

Self-care confidence may be the key: A cross-sectional study on the association between cognition and self-care behaviors in adults with heart failure

BACKGROUND

Self-care, a key element of heart failure care, is challenging for patients with impaired cognition. Mechanisms through which cognitive impairment affects self-care are not currently well defined but evidence from other patient populations suggests that self-efficacy, or task-specific confidence, mediates the relationship between cognitive functioning and patient behaviors such as self-care.

OBJECTIVE

The aim of this study was to test the mediating role of self-care confidence in the relationship between cognition and self-care behaviors.

DESIGN

A secondary analysis of data from a cross-sectional study.

SETTING

Outpatient heart failure clinics in 28 Italian provinces.

PARTICIPANTS

628 Italian heart failure patients.

METHODS

We used the Self-Care of Heart Failure Index v.6.2 to measure self-care maintenance, self-care management, and self-care confidence. Cognition was assessed with the Mini Mental State Examination. Structural equation modeling was used to analyze the data.

RESULTS

Participants were 73 years old on average (SD=11), mostly (58%) male and mostly (77%) in New York Heart Association functional classes II and III. The mediation model showed excellent fit (comparative fit index=1.0; root mean square error of approximation=0.02): Self-care confidence totally mediated the relationship between cognition and self-care maintenance and management.

CONCLUSION

Cognition affects self-care behaviors indirectly, through self-care confidence. Interventions aimed at improving self-care confidence may improve self-care, even in heart failure patients with impaired cognition.

Exercise-based rehabilitation for heart failure: systematic review and meta-analysis

OBJECTIVE

To update the Cochrane systematic review of exercise-based cardiac rehabilitation (CR) for heart failure.

METHODS

A systematic review and meta-analysis of randomised controlled trials was undertaken. MEDLINE, EMBASE and the Cochrane Library were searched up to January 2013. Trials with 6 or more months of follow-up were included if they assessed the effects of exercise interventions alone or as a component of comprehensive CR programme compared with no exercise control.

RESULTS

33 trials were included with 4740 participants predominantly with a reduced ejection fraction (<40%) and New York Heart Association class II and III. Compared with controls, while there was no difference in pooled all-cause mortality between exercise CR with follow-up to 1 year (risk ratio (RR) 0.93; 95% CI 0.69 to 1.27, p=0.67), there was a trend towards a reduction in trials with follow-up beyond 1 year (RR 0.88; 0.75 to 1.02, 0.09). Exercise CR reduced the risk of overall (RR 0.75; 0.62 to 0.92, 0.005) and heart failure-specific hospitalisation (RR 0.61; 0.46 to 0.80, 0.0004) and resulted in a clinically important improvement in the Minnesota Living with Heart Failure questionnaire (mean difference: -5.8 points, -9.2 to -2.4, 0.0007). Univariate meta-regression analysis showed that these benefits were independent of the type and dose of exercise CR, and trial duration of follow- up, quality or publication date.

CONCLUSIONS

This updated Cochrane review shows that improvements in hospitalisation and health-related quality of life with exercise-based CR appear to be consistent across patients regardless of CR programme characteristics and may reduce mortality in the longer term. An individual participant data meta-analysis is needed to provide confirmatory evidence of the importance of patient subgroup and programme level characteristics (eg, exercise dose) on outcome.

Study of adherence to exercise in heart failure: the HEART camp trial protocol

BACKGROUND

Adherence to the Heart Failure Society of America (HFSA) 2010 guidelines recommending 30 minutes of supervised moderate intensity exercise five days per week is difficult for patients with heart failure (HF). Innovative programs are needed to assist HF patients to adhere to long-term exercise. The objective of this prospective randomized two-group repeated measures experimental design is to determine the efficacy of a behavioral exercise training intervention on long-term adherence to exercise at 18 months in patients with heart failure.

METHODS/DESIGN

A sample size of 246 subjects with heart failure will be recruited over a 3 year period. All subjects receive a cardiopulmonary exercise test and 9 supervised exercise training sessions during a 3 week run-in period prior to randomization. Subjects completing at least 6 of 9 training sessions are randomized to the HEART Camp Intervention group (HC) or to a standard care (SC) exercise group. The HC intervention group receives cognitive-behavioral strategies that address the intervention components of knowledge, attitudes, self-efficacy, behavioral self-management skills and social support. The SC group is provided access to the exercise facility and regular facility staff for the 18 month study period. The primary aim is to evaluate the effect of HEART Camp on adherence to exercise, with our central hypothesis that the HC group will have significantly better adherence to exercise at 18 months. Secondary aims include evaluating which components of the HEART Camp intervention mediate the effects of the intervention on adherence; evaluating the effect of HEART Camp on specific health outcomes; exploring selected demographic variables (race, gender, age) as potential moderators of the effect of the HEART Camp intervention on adherence; and exploring the perceptions and experiences that contextualize exercise adherence.

DISCUSSION

The HEART Camp intervention is the first to test a multi-component intervention designed to improve long-term adherence to exercise behavior in patients with HF. Improving long-term adherence to exercise is the logical first step to ensure the required dose of exercise that is necessary to realize beneficial health outcomes and reduce costs in this burdensome chronic illness.

TRIAL REGISTRATION

Clincaltrials.gov NCT01658670.

Exercise self-efficacy and symptoms of depression after cardiac rehabilitation: predicting changes over time using a piecewise growth curve analysis

BACKGROUND

Cardiac rehabilitation is often recommended after experiencing a cardiac event and has been shown to significantly improve health outcomes among patients. Several psychosocial variables have been linked with cardiac rehabilitation program success, including exercise self-efficacy. However, little is known about temporal patterns in patients' exercise self-efficacy after program completion.

OBJECTIVE

This study examined changes in exercise self-efficacy among 133 cardiac rehabilitation patients and whether symptoms of depression impacted the rate of change in exercise self-efficacy.

METHOD

Participants completed questionnaires at the beginning and end of cardiac rehabilitation and at 6-month intervals for 2 years.

RESULTS

Growth curve analyses showed that exercise self-efficacy levels were highest at the beginning of cardiac rehabilitation, significantly declined 6 months after cardiac rehabilitation, and leveled off over the next 18 months. Results also showed that baseline depressive symptoms interacted with time: Compared with participants with fewer symptoms, participants high in depressive symptoms began cardiac rehabilitation with lower levels of exercise self-efficacy and evidenced significant declines 6 months after cardiac rehabilitation. At no time were they equal to their counterparts in exercise self-efficacy, and their means were lower 2 years after cardiac rehabilitation than before cardiac rehabilitation.

CONCLUSIONS

Our findings imply that patients show unrealistic optimism surrounding the ease of initiating and maintaining an exercise program and that integrating efficacy-building activities into cardiac rehabilitation, especially for patients who show signs of distress, is advisable.

Self-efficacy strategies to improve exercise in patients with heart failure: A systematic review

BACKGROUND

Despite exercise is recommended as an adjunct to medication therapy in patients with heart failure (HF), non-adherence to exercise is a major problem. While improving self-efficacy is an effective way to increase physical activity, the evidence concerning the relationship between strategies to enhance self-efficacy and exercise among HF has not been systematically reviewed. The objective of this systematic review is to assess the effect of interventions to change the self-efficacy on exercise in patients with HF.

METHODS

A systematic database search was conducted for articles reporting exercise self-efficacy interventions. Databases such as PubMed, ProQuest, CINAHL, Scopus, and PsycINFO, and the Cochrane Library were searched with restrictions to the years 2000-June 2014. A search of relevant databases identified 10 studies. Published randomized controlled intervention studies focusing strategies to change self-efficacy to exercise adherence in HF were eligible for inclusion. In addition, studies that have applied self-efficacy-based interventions to improve exercise are discussed.

RESULTS

Limited published data exist evaluating the self-efficacy strategies to improve exercise in HF. Dominant strategies to improve patients' self-efficacy were performance accomplishments, vicarious experience, verbal persuasion, emotional arousal.

CONCLUSION

Evidence from some trials supports the view that incorporating the theory of self-efficacy into the design of an exercise intervention is beneficial. Moreover, exercise interventions aimed at integrating the four strategies of exercise self-efficacy can have positive effects on confidence and the ability to initiate exercise and recover HF symptoms. Findings of this study suggest that a positive relationship exists between self-efficacy and initiating and maintaining exercise in HF, especially in the short-term period.

Exercise-based rehabilitation for heart failure

BACKGROUND

Previous systematic reviews and meta-analyses consistently show the positive effect of exercise-based rehabilitation for heart failure (HF) on exercise capacity; however, the direction and magnitude of effects on health-related quality of life, mortality and hospital admissions in HF remain less certain. This is an update of a Cochrane systematic review previously published in 2010.

OBJECTIVES

To determine the effectiveness of exercise-based rehabilitation on the mortality, hospitalisation admissions, morbidity and health-related quality of life for people with HF. Review inclusion criteria were extended to consider not only HF due to reduced ejection fraction (HFREF or 'systolic HF') but also HF due to preserved ejection fraction (HFPEF or 'diastolic HF').

SEARCH METHODS

We updated searches from the previous Cochrane review. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue1, 2013) from January 2008 to January 2013. We also searched MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO) and PsycINFO (Ovid) (January 2008 to January 2013). We handsearched Web of Science, bibliographies of systematic reviews and trial registers (Controlled-trials.com and Clinicaltrials.gov).

SELECTION CRITERIA

Randomised controlled trials of exercise-based interventions with six months' follow-up or longer compared with a no exercise control that could include usual medical care. The study population comprised adults over 18 years and were broadened to include individuals with HFPEF in addition to HFREF.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all identified references and rejected those that were clearly ineligible. We obtained full-text papers of potentially relevant trials. One review author independently extracted data from the included trials and assessed their risk of bias; a second review author checked data.

MAIN RESULTS

We included 33 trials with 4740 people with HF predominantly with HFREF and New York Heart Association classes II and III. This latest update identified a further 14 trials. The overall risk of bias of included trials was moderate. There was no difference in pooled mortality between exercise-based rehabilitation versus no exercise control in trials with up to one-year follow-up (25 trials, 1871 participants: risk ratio (RR) 0.93; 95% confidence interval (CI) 0.69 to 1.27, fixed-effect analysis). However, there was trend towards a reduction in mortality with exercise in trials with more than one year of follow-up (6 trials, 2845 participants: RR 0.88; 95% CI 0.75 to 1.02, fixed-effect analysis). Compared with control, exercise training reduced the rate of overall (15 trials, 1328 participants: RR 0.75; 95% CI 0.62 to 0.92, fixed-effect analysis) and HF specific hospitalisation (12 trials, 1036 participants: RR 0.61; 95% CI 0.46 to 0.80, fixed-effect analysis). Exercise also resulted in a clinically important improvement superior in the Minnesota Living with Heart Failure questionnaire (13 trials, 1270 participants: mean difference: -5.8 points; 95% CI -9.2 to -2.4, random-effects analysis) - a disease specific health-related quality of life measure. However, levels of statistical heterogeneity across studies in this outcome were substantial. Univariate meta-regression analysis showed that these benefits were independent of the participant's age, gender, degree of left ventricular dysfunction, type of cardiac rehabilitation (exercise only vs. comprehensive rehabilitation), mean dose of exercise intervention, length of follow-up, overall risk of bias and trial publication date. Within these included studies, a small body of evidence supported exercise-based rehabilitation for HFPEF (three trials, undefined participant number) and when exclusively delivered in a home-based setting (5 trials, 521 participants). One study reported an additional mean healthcare cost in the training group compared with control of USD3227/person. Two studies indicated exercise-based rehabilitation to be a potentially cost-effective use of resources in terms of gain in quality-adjusted life years (QALYs) and life-years saved.

AUTHORS' CONCLUSIONS

This updated Cochrane review supports the conclusions of the previous version of this review that, compared with no exercise control, exercise-based rehabilitation does not increase or decrease the risk of all-cause mortality in the short term (up to 12-months' follow-up) but reduces the risk of hospital admissions and confers important improvements in health-related quality of life. This update provides further evidence that exercise training may reduce mortality in the longer term and that the benefits of exercise training on appear to be consistent across participant characteristics including age, gender and HF severity. Further randomised controlled trials are needed to confirm the small body of evidence seen in this review for the benefit of exercise in HFPEF and when exercise rehabilitation is exclusively delivered in a home-based setting.

A theory-based exercise intervention in patients with heart failure: A protocol for randomized, controlled trial

BACKGROUND

Regular exercise has been associated with improved quality of life (QoL) in patients with heart failure (HF). However, less is known on the theoretical framework, depicting how educational intervention on psychological, social, and cognitive variables affects physical activity (PA). The purpose of this study is to assess the effectiveness of a social cognitive theory-based (SCT-based) exercise intervention in patients with HF.

MATERIALS AND METHODS

This is a randomized controlled trial, with measurements at baseline, immediately following the intervention, and at 1, 3, and 6 months follow-up. Sixty patients who are referred to the cardiac rehabilitation (CR) unit and meet the inclusion criteria will be randomly allocated to either an intervention group or a usual-care control group. Data will be collected using various methods (i.e., questionnaires, physical tests, paraclinical tests, patients' interviews, and focus groups). The patients in the intervention group will receive eight face-to-face counseling sessions, two focus groups, and six educational sessions over a 2-month period. The intervention will include watching videos, using book and pamphlets, and sending short massage services to the participants. The primary outcome measures are PA and QoL. The secondary outcome measures will be the components of SCT, heart rate and blood pressure at rest, body mass index, left ventricular ejection fraction, exercise capacity, and maximum heart rate.

CONCLUSION

The findings of this trial may assist with the development of a theoretical model for exercise intervention in CR. The intervention seems to be promising and has the potential to bridge the gap of the usually limited and incoherent provision of educational care in the CR setting.

Psychological responses and adherence to exercise in heart failure

PURPOSE

The purpose of this study was to describe psychological effects and exercise adherence during a multicomponent exercise training intervention.

METHODS

A sample of 42 patients with heart failure were randomized into an exercise (INV) group (n = 22) and an attention control (AC) group (n = 20). The exercise protocol included two 12-week phases, a structured phase and a self-managed phase. The psychological responses assessed were mood states and exercise self-efficacy. To meet the second purpose of the study, the exercise group was dichotomized based on the number of sessions completed to create two adherence subgroups.

FINDINGS

Results indicate self-efficacy improved for the INV group and was maintained during the self-management phase. The adherence subgroups demonstrated different patterns for weekly exercise. Depression and confusion scores improved for the high-adherence group in contrast to worsening for the low-adherence group.

CONCLUSIONS

Results suggest a need for further study of the psychological responses of exercise adherence for patients with heart failure.

CLINICAL RELEVANCE

The study indicates the importance of continuous assessment of exercise participation and longer term adherence support for patients with heart failure.

Effects of Exercise Training versus Attention on Plasma B-type Natriuretic Peptide, 6-Minute Walk Test and Quality of Life in Individuals with Heart Failure

PURPOSE

The purpose of this study was to compare an Exercise Training Group (EX) with an Attention-Control Group (AT-C) to more specifically assess the impact of exercise training on individuals with heart failure (HF).

METHODS

Forty-two individuals with HF were randomized to AT-C or EX that met with the same frequency and format of investigator interaction. Baseline, 12- and 24-week measurements of B-type naturetic peptide (BNP), 6-minute walk test (6-MWT), and the Kansas City Cardiomyopathy Questionnaire (KCCQ) were obtained.

RESULTS

BNP tended to increase in the AT-C while remaining stable in the EX over time. A clinically significant increase in 6-MWT was demonstrated by the EX but not the AT-C. The EX achieved a clinically significant change on the KCCQ at 12 weeks, with further improvement by 24 weeks, while the AT-C demonstrated a clinically significant change at 24 weeks.

CONCLUSIONS

Attention alone was inadequate to positively impact BNP levels or 6-MWT distances, but did have a positive impact on quality of life after 24 weeks. Although exercise offers enhanced benefits, individuals with HF unable to participate in an exercise program may still gain quality of life benefits from participation in a peer-support group that discusses topics pertinent to HF.

Adherence of heart failure patients to exercise: barriers and possible solutions: a position statement of the Study Group on Exercise Training in Heart Failure of the Heart Failure Association of the European Society of Cardiology

The practical management of heart failure remains a challenge. Not only are heart failure patients expected to adhere to a complicated pharmacological regimen, they are also asked to follow salt and fluid restriction, and to cope with various procedures and devices. Furthermore, physical training, whose benefits have been demonstrated, is highly recommended by the recent guidelines issued by the European Society of Cardiology, but it is still severely underutilized in this particular patient population. This position paper addresses the problem of non-adherence, currently recognized as a main obstacle to a wide implementation of physical training. Since the management of chronic heart failure and, even more, of training programmes is a multidisciplinary effort, the current manuscript intends to reach cardiologists, nurses, physiotherapists, as well as psychologists working in the field.