Accelerometer-Measured Daily Activity Levels and Related Factors in Patients With Heart Failure

A scoping review on advancements in noninvasive wearable technology for heart failure management

Wearables offer a promising solution for enhancing remote monitoring (RM) of heart failure (HF) patients by tracking key physiological parameters. Despite their potential, their clinical integration faces challenges due to the lack of rigorous evaluations. This review aims to summarize the current evidence and assess the readiness of wearables for clinical practice using the Medical Device Readiness Level (MDRL). A systematic search identified 99 studies from 3112 found articles, with only eight being randomized controlled trials. Accelerometery was the most used measurement technique. Consumer-grade wearables, repurposed for HF monitoring, dominated the studies with most of them in the feasibility testing stage (MDRL 6). Only two of the described wearables were specifically designed for HF RM, and received FDA approval. Consequently, the actual impact of wearables on HF management remains uncertain due to limited robust evidence, posing a significant barrier to their integration into HF care.

Behavioural digital biomarkers enable real-time monitoring of patient-reported outcomes: a substudy of the multicentre, prospective observational SafeHeart study

AIMS

Patient-reported outcome measures (PROMs) serve multiple purposes, including shared decision-making and patient communication, treatment monitoring, and health technology assessment. Patient monitoring using PROMs is constrained by recall and non-response bias, respondent burden, and missing data. We evaluated the potential of behavioural digital biomarkers obtained from a wearable accelerometer to achieve personalized predictions of PROMs.

METHODS AND RESULTS

Data from the multicentre, prospective SafeHeart study conducted at Amsterdam University Medical Center in the Netherlands and Copenhagen University Hospital, Rigshospitalet in Copenhagen, Denmark, were used. The study enrolled patients with an implantable cardioverter defibrillator between May 2021 and September 2022 who then wore wearable devices with raw acceleration output to capture digital biomarkers reflecting physical behaviour. To collect PROMs, patients received the Kansas City Cardiomyopathy Questionnaire (KCCQ) and EuroQoL 5-Dimensions 5-Level (EQ5D-5L) questionnaire at two instances: baseline and after six months. Multivariable Tobit regression models were used to explore associations between digital biomarkers and PROMs, specifically whether digital biomarkers could enable PROM prediction. The study population consisted of 303 patients (mean age 62.9 ± 10.9 years, 81.2% male). Digital biomarkers showed significant correlations to patient-reported physical and social limitations, severity and frequency of symptoms, and quality of life. Prospective validation of the Tobit models indicated moderate correlations between the observed and predicted scores for KCCQ [concordance correlation coefficient (CCC) = 0.49, mean difference: 1.07 points] and EQ5D-5L (CCC = 0.38, mean difference: 0.02 points).

CONCLUSION

Wearable digital biomarkers correlate with PROMs, and may be leveraged for real-time prediction. These findings hold promise for monitoring of PROMs through wearable accelerometers.

Associations of fear of physical activity, coping style and self-reported exercise behavior in patients with chronic heart failure

AIMS

Fear of physical activity (PA) is discussed as a barrier to regular exercise in patients with heart failure (HF), but HF-specific theoretical concepts are lacking. This study examined associations of fear of PA, heart-focused anxiety and trait anxiety with clinical characteristics and self-reported PA in outpatients with chronic HF. It was also investigated whether personality-related coping styles for dealing with health threats impact fear of PA via symptom perception.

METHODS AND RESULTS

This cross-sectional study enrolled 185 HF outpatients from five hospitals (mean age 62 ± 11 years, mean ejection fraction 36.0 ± 12%, 24% women). Avoidance of PA, sports/exercise participation (yes/no) and the psychological characteristics were assessed by self-reports. Fear of PA was assessed by the Fear of Activity in Situations-Heart Failure (FActS-HF15) questionnaire. In multivariable regression analyses higher NYHA class (b = 0.26, p = 0.036) and a higher number of HF drugs including antidepressants (b = 0.25, p = 0.017) were independently associated with higher fear of PA, but not with heart-focused fear and trait anxiety. Of the three anxiety scores only increased fear of PA was independently associated with more avoidance behavior regarding PA (b = 0.45, SE = 0.06, p < 0.001) and with increased odds of no sports/exercise participation (OR = 1.34, 95% CI 1.03-1.74, p = 0.028). Attention towards cardiac symptoms and symptom distress were positively associated with fear of PA (p < 0.001), which explained higher fear of PA in patients with a vigilant (directing attention towards health threats) coping style (p = 0.004).

CONCLUSIONS

Fear of PA assessed by the FActS-HF15 is a specific type of anxiety in patients with HF. Attention towards and being distressed by HF symptoms appear to play a central role in fear of PA, particularly in vigilant patients who are used to direct their attention towards health threats. These findings provide approaches for tailored interventions to reduce fear of PA and to increase PA in patients with HF.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT02898246.

Daily physical activity and prognostic implications in patients with heart failure: an accelerometer study

BACKGROUND

Physical activity (PA) measured by accelerometry is proposed as a novel trial endpoint for heart failure (HF). However, standardised methods and associations with established markers are lacking. This study aimed to examine PA measurements and accelerometer repeatability in patients with HF and age- and sex-matched controls, and study correlations with established prognostic HF markers, body composition, and quality of life (QoL).

METHODS

Accelerometry was performed in 105 patients with HF with left ventricular ejection fraction (LVEF) ≤ 40% and in 46 controls. Participants also underwent dual X-ray absorptiometry, cardiopulmonary exercise testing, a six-minute walking test (6MWT), echocardiography, and NT-proBNP measurement, and completed a QoL questionnaire.

RESULTS

Average acceleration was markedly reduced in patients with HF compared with healthy controls (16.1 ± 4.8 mg vs 27.2 ± 8.5 mg, p < 0.001). Healthy controls spent a median daily 56 min (IQR 41-96 min) in moderate-to-vigorous PA (MVPA), whereas HF patients spent only 12 min (IQR 6-24) in MVPA. In HF patients, average acceleration correlated moderately with 6MWT (R = 0.41, p < 0.001) and maximal oxygen uptake (peak VO2) (R = 0.36, p < 0.001) but not with NT-proBNP, LVEF, or QoL. Patients in NYHA class II showed a higher average acceleration than patients in NYHA III (16.6 ± 4.9 mg vs 14.0 ± 3.6 mg, p = 0.01).

CONCLUSIONS

Daily PA was severely reduced in patients with HF compared with healthy controls. In HF patients, we found moderate correlations of accelerometer measurements with markers of physical capacity but not with LVEF or NT-proBNP.

TRIAL REGISTRATION

NCT05063955. Registered 01 June 2021-retrospectively registered.

Psychometric properties of the Japanese version of the Self-Care of Heart Failure Index version 7.2

AIMS

It is more important for patients with heart failure (HF) to objectively identify their self-care status. The Self-Care of Heart Failure Index (SCHFI) version 7.2 is a reliable and valid instrument comprising three scales: self-care maintenance, symptom perception, and self-care management. We aimed to translate the SCHFI v.7.2 into Japanese and test its validity and reliability.

METHODS AND RESULTS

This was a cross-sectional study. Two translators performed forward and backward translations between English and Japanese. To assess structural validity, confirmatory factor analyses were performed using the structure of the original version. To assess convergent validity, the associations between each scale and self-care self-efficacy were evaluated. To assess internal consistency, model-based internal consistency coefficients were calculated. Participants were 314 Japanese outpatients with HF (mean age: 72.8 ± 12.8 years). Regarding structural validity, all scales showed adequate model fit indices, supporting a two-factor structure with items similar to those in the original version. However, to improve the model fit indices, it was necessary to add error correlations for the self-care maintenance and symptom perception scales. Regarding convergent validity, all scales showed significant associations with self-care self-efficacy. Regarding internal consistency, the model-based internal consistency coefficients were sufficient for all scales (0.739, 0.908, and 0.783 for the self-care maintenance, symptom perception, and self-care management scales, respectively).

CONCLUSION

The Japanese version of the SCHFI v.7.2 had adequate validity and reliability. This instrument is useful for assessing self-care in Japanese HF patients. However, factors influencing self-care should be considered when interpreting results.

Network analysis of perception of exercise benefits/barriers and kinesiophobia among patients with cardiovascular diseases

BACKGROUND

Perception of exercise benefits/barriers and kinesiophobia are important predictors of low exercise behaviors in patients with cardiovascular diseases (CVDs). Little is known about the complex intercorrelations between different components of perception of exercise benefits/barriers and kinesiophobia.

OBJECTIVES

To identify the central components of kinesiophobia and to explore the interconnectedness between perception of exercise benefits/barriers and kinesiophobia.

METHODS

A total of 258 patients with CVDs were recruited in this study. The Tampa Scale for Kinesiophobia Heart and the Exercise Benefits/Barriers Scale were used to assess kinesiophobia and perception of exercise benefits/barriers. R software was used to visualize the networks and analyze the centrality of the networks. The index "expected influence" and "bridge expected influence" were employed to identify the central components and the bridge components of the networks.

RESULTS

In the item network of kinesiophobia, three items ("It is really not safe for a person in my condition to be physically active/exercise", "I cannot do the same things as others because there is a too big risk that I will get heart problems", and "If I tried to be physically active/exercise my heart problem would increase") had the highest expected influence. In the exercise benefits/barriers-kinesiophobia network, the dimension of physical exertion had the highest positive bridge expected influence, while psychological outlook had highest negative value.

CONCLUSIONS

The three central components of kinesiophobia and the two bridge components (perception exercise barriers of physical exertion and perception exercise benefits of psychological outlook) should be targeted in specific intervention for relieving kinesiophobia and further promoting exercise behaviors.

Measurement properties of assessment tools of Kinesophobia in patients with cardiovascular disease: A systematic review

Objectives

This study aimed to evaluate the measurement properties and methodological quality of assessment tools for Kinesophobia among patients with cardiovascular disease and provide a reference for healthcare professionals in selecting high-quality assessment tools.

Methods

A systematic search was performed on specific databases: Embase, the Cochrane Library, PubMed, Web of Science, China National Knowledge Infrastructure, Wanfang database, China Biological Medicine disc, CINAHL, and China Science and Technology Journal Database, from inception to April 1, 2023. The researchers retrieved studies on the measurement attributes of the exercise fear scale in patients with cardiovascular diseases. They also traced back the references of the included studies to supplement relevant literature. According to the inclusion and exclusion criteria, screening and data extraction were independently undertaken by two reviewers. Two researchers individually used the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) Risk of Bias Checklist to assess the methodological quality of the scale, applied the COSMIN criteria to evaluate the measurement properties of the scale, and used a modified Grading, Recommendations, Assessment, Development, and Evaluation system to assess the certainty of evidence.

Results

Seventeen studies were identified that reported the psychometric properties of six patient reported outcome measurement tools (included different languages version) The methodological quality of content validity was adequate in only two studies, the remaining patient-reported outcome measures demonstrated doubtful content validity. Limited information on cross-cultural validity/measurement invariance, measurement error, and responsiveness was retrieved. The Swedish version and the Chinese version of the Tampa Scale for Kinesiophobia Heart were graded "A." The remaining instruments were graded "B."

Conclusions

The methodological and measurement attributes of the Swedish and Chinese versions of the Tampa Scale for Kinesiophobia Heart are relatively high quality and can be tentatively recommended. The measurement properties of the remaining scales remain to be verified.

Informing behaviour change intervention design using systematic review with Bayesian meta-analysis: physical activity in heart failure

Embracing the Bayesian approach, we aimed to synthesise evidence regarding barriers and enablers to physical activity in adults with heart failure (HF) to inform behaviour change intervention. This approach helps estimate and quantify the uncertainty in the evidence and facilitates the synthesis of qualitative and quantitative studies. Qualitative evidence was annotated using the Theoretical Domains Framework and represented as a prior distribution using an expert elicitation task. The maximum a posteriori probability (MAP) for the probability distribution for the log OR was used to estimate the relationship between physical activity and each determinant according to qualitative, quantitative, and qualitative and quantitative evidence combined. The probability distribution dispersion (SD) was used to evaluate uncertainty in the evidence. Three qualitative and 16 quantitative studies were included (N = 2739). High pro-b-type natriuretic peptide (MAP = -1.16; 95%CrI: [-1.21; -1.11]) and self-reported symptoms (MAP = - 0.48; 95%CrI: [ -0.40; -0.55]) were suggested as barriers to physical activity with low uncertainty (SD = 0.18 and 0.19, respectively). Modifiable barriers were symptom distress (MAP = -0.46; 95%CrI: [-0.68; -0.24], SD = 0.36), and negative attitude (MAP = -0.40; 95%CrI: [-0.49; -0.31], SD = 0.26). Modifiable enablers were social support (MAP = 0.56; 95%CrI: [0.48; 0.63], SD = 0.26), self-efficacy (MAP = 0.43; 95%CrI: [0.32; 0.54], SD = 0.37), positive physical activity attitude (MAP = 0.92; 95%CrI: [0.77; 1.06], SD = 0.36).

Physical activity and relationship to physical function, quality of life, and cognitive function in older patients with acute decompensated heart failure

BACKGROUND

Volitional physical activity level is predictive of a variety of health outcomes, but has not been examined in patients recently hospitalized for acute decompensated HF (ADHF).

METHODS

Ten to 14 days after index hospitalization for ADHF, 93 participants wore a wrist-mounted triaxial accelerometer (ActiGraph GT3X+) to objectively quantify sedentary behavior, light physical activity, and moderate-to-vigorous physical activity. Levels were compared to 2 groups of age-matched NHANES participants: healthy and chronic, stable HF. The relationship between physical activity levels and physical function [Short Physical Performance Battery (SPPB)], HF-specific quality-of-life (QOL) [Kansas City Cardiomyopathy Questionnaire (KCCQ)], and cognition [Montreal Cognitive Assessment (MOCA)] were examined.

RESULTS

ADHF participants accumulated a median 1,008 (IQR 896, 1,109) minutes of sedentary time, 88 (57, 139) minutes of light physical activity, and 10 (6, 25) minutes of moderate-to-vigorous physical activity per day. Sedentary time, light physical activity, or moderate-to-vigorous activity did not differ by sex or EF subtype. ADHF participants spent only 9% of awake time nonsedentary, compared to 34% and 27% for healthy adults and adults with chronic, stable HF, respectively. Among ADHF participants, SPPB, KCCQ, and MOCA scores did not differ among quartiles of total physical activity.

CONCLUSIONS

Older patients recently hospitalized for ADHF have very low levels of physical activity and high levels of sedentary time, both of which may be potential targets for interventions in this high-risk population. Physical activity level was not significantly associated with objectively measured physical function, QOL, or cognition, suggesting that this measure provides independent information regarding the patient experience of living with HF.

TRIAL REGISTRATION

NCT02196038, https://clinicaltrials.gov/ct2/show/NCT02196038.

Objectively measured physical activity levels and adherence to physical activity guidelines in people with multimorbidity-A systematic review and meta-analysis

Objective

To determine levels of objectively measured physical activity (PA) and the proportion of adults with multimorbidity that adheres to PA guidelines.

Methods

All studies, where PA was measured at baseline using an activity monitor in an adult (≥18 years) multimorbid (≥80% of the population had ≥2 chronic conditions) population. A systematic literature search was performed in Medline, EMBASE, CINAHL, CENTRAL, ClinicalTrials.gov, opengrey.eu and google.com from inception up until 18^th of January 2022. Risk of bias was assessed with a modified version of the Quality Assessment Tool for Quantitative Studies. A random-effects meta-analyses was performed to estimate daily minutes of sedentary behavior (SB), light PA (LPA), moderate PA (MPA), moderate to vigorous PA (MVPA) and steps. Proportions adhering to PA guidelines was narratively synthesized. Certainty of evidence was determined using The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Results

Fifteen studies (2,172 participants) were included. The most frequent combination of conditions were type 2 diabetes and hypertension (six studies). Participants spent a daily average of 500.5 (95% CI: 407.1 to 593.9) minutes in SB, 325.6 (95% CI: 246.4 to 404.7 minutes in LPA and 32.7 (95% CI: 20.2 to 45.3) minutes in MVPA. The mean daily number of steps was 5,145 (95% CI: 4264 to 6026) for people in free-living conditions. The proportion adhering to PA guidelines ranged widely (7.4% to 43%). All studies were rated as at high risk of bias and the certainty of evidence was very low.

Conclusions

PA levels and adherence varied from low to above guideline recommended levels for adults with chronic conditions, depending on PA intensity. The very low certainty of evidence calls for high quality studies focusing on detailed descriptions of PA behavior in people with multimorbidity.

PROSPERO registration number

CRD42020172456.

Fear of movement and its associated psychosocial factors in heart failure patients: A cross-sectional study

AIMS

Fear of movement is a significant obstacle to daily activities, which may lead to adverse outcomes in patients with heart failure. This study aimed to examine the prevalence of fear of movement and to identify psychosocial factors associated with fear of movement in heart failure patients.

METHODS AND RESULTS

In this cross-sectional study, a total of 305 heart failure patients were recruited from three cardiovascular units of a university hospital. Self-reported questionnaires were used to measure fear of movement, cardiac anxiety, depressive symptoms, subjective social status, education, monthly income, and employment status. The results showed that 178 (58.4%) patients were accompanied with fear of movement. Hierarchical linear regression analysis showed that scores for cardiac anxiety (β=0.254, p < 0.001) and depressive symptoms (β=0.308, p < 0.001), as well as being employed (β=0.186, p < 0.001) were positively associated with fear of movement score, while the score for subjective social status (β=-0.101, p = 0.038) was negatively associated with fear of movement score. The four independent variables accounted for 30.3% of the variance in fear of movement.

CONCLUSIONS

Fear of movement is common in patients with heart failure. Cardiac anxiety, depressive symptoms, subjective social status, and employment status were associated with patients' fear of movement. This indicates that measures should be taken to screen and manage patients' fear of movement. Furthermore, alleviating cardiac anxiety and depressive symptoms may be important to consider in relieving fear of movement in heart failure patients, especially for those who are employed and with low subjective social status.

Accelerometer-assessed physical behavior and the association with clinical outcomes in implantable cardioverter-defibrillator recipients: A systematic review

Background

Current implantable cardioverter-defibrillator (ICD) devices are equipped with a device-embedded accelerometer capable of capturing physical activity (PA). In contrast, wearable accelerometer-based methods enable the measurement of physical behavior (PB) that encompasses not only PA but also sleep behavior, sedentary time, and rest-activity patterns.

Objective

This systematic review evaluates accelerometer-based methods used in patients carrying an ICD or at high risk of sudden cardiac death.

Methods

Papers were identified via the OVID MEDLINE and OVID EMBASE databases. PB could be assessed using a wearable accelerometer or an embedded accelerometer in the ICD.

Results

A total of 52 papers were deemed appropriate for this review. Out of these studies, 30 examined device-embedded accelerometry (189,811 patients), 19 examined wearable accelerometry (1601 patients), and 3 validated wearable accelerometry against device-embedded accelerometry (106 patients). The main findings were that a low level of PA after implantation of the ICD and a decline in PA were both associated with an increased risk of mortality, heart failure hospitalization, and appropriate ICD shock. Second, PA was affected by cardiac factors (eg, onset of atrial fibrillation, ICD shocks) and noncardiac factors (eg, seasonal differences, societal factors).

Conclusion

This review demonstrated the potential of accelerometer-measured PA as a marker of clinical deterioration and ventricular arrhythmias. Notwithstanding that the evidence of PB assessed using wearable accelerometry was limited, there seems to be potential for accelerometers to improve early warning systems and facilitate preventative and proactive strategies.

The Relationship Between Objectively Measured Step Count, Clinical Characteristics, and Quality of Life Among Depressed Patients Recently Hospitalized With Systolic Heart Failure

OBJECTIVE

Physical activity (PA) can improve symptoms of both depression and heart failure (HF), but objective activity data among recently hospitalized HF patients with comorbid depression are lacking. We examined PA and the relationship between daily step counts and mood, health-related quality of life (HRQoL), and heart health among patients enrolled in a clinical trial treating HF and comorbid depression.

METHODS

We screened hospitalized patients with systolic HF (left ventricular ejection fraction [LVEF] ≤45%) and New York Heart Association class II-IV symptoms for depression using the two-item Patient Health Questionnaire (PHQ-2) and telephoned screen-positive patients to administer the PHQ-9 2 weeks after discharge. If the patient scored PHQ-9 ≥10 and agreed to continue in our study, we administered our baseline assessment and mailed them an armband accelerometer. We instructed patients to wear the armbands for 7 days before returning them and classified their data as "usable" if they wore it ≥10 hours per day on ≥4 separate days.

RESULTS

We mailed accelerometers to 531 depressed HF patients, and 222 (42%) returned them with usable data. Their median age was 64 years, 54% were women, 23% were non-White, and they walked a median of 1170 steps daily. Higher median daily step counts were associated with lower New York Heart Association class and better physical- and HF-specific HRQoL, but not mood symptoms, mental HRQoL, or LVEF.

CONCLUSIONS

Patients with HF and comorbid depression are generally sedentary after hospital discharge. Although mood symptoms and LVEF were unrelated to objective PA, patients with higher step counts self-reported better HRQoL.Trial Registration:ClinicalTrials.gov identifier NCT02044211.

The Impact of Wearable Technologies in Health Research: Scoping Review

Background

Wearable devices hold great promise, particularly for data generation for cutting-edge health research, and their demand has risen substantially in recent years. However, there is a shortage of aggregated insights into how wearables have been used in health research.

Objective

In this review, we aim to broadly overview and categorize the current research conducted with affordable wearable devices for health research.

Methods

We performed a scoping review to understand the use of affordable, consumer-grade wearables for health research from a population health perspective using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) framework. A total of 7499 articles were found in 4 medical databases (PubMed, Ovid, Web of Science, and CINAHL). Studies were eligible if they used noninvasive wearables: worn on the wrist, arm, hip, and chest; measured vital signs; and analyzed the collected data quantitatively. We excluded studies that did not use wearables for outcome assessment and prototype studies, devices that cost >€500 (US $570), or obtrusive smart clothing.

Results

We included 179 studies using 189 wearable devices covering 10,835,733 participants. Most studies were observational (128/179, 71.5%), conducted in 2020 (56/179, 31.3%) and in North America (94/179, 52.5%), and 93% (10,104,217/10,835,733) of the participants were part of global health studies. The most popular wearables were fitness trackers (86/189, 45.5%) and accelerometer wearables, which primarily measure movement (49/189, 25.9%). Typical measurements included steps (95/179, 53.1%), heart rate (HR; 55/179, 30.7%), and sleep duration (51/179, 28.5%). Other devices measured blood pressure (3/179, 1.7%), skin temperature (3/179, 1.7%), oximetry (3/179, 1.7%), or respiratory rate (2/179, 1.1%). The wearables were mostly worn on the wrist (138/189, 73%) and cost <€200 (US $228; 120/189, 63.5%). The aims and approaches of all 179 studies revealed six prominent uses for wearables, comprising correlations—wearable and other physiological data (40/179, 22.3%), method evaluations (with subgroups; 40/179, 22.3%), population-based research (31/179, 17.3%), experimental outcome assessment (30/179, 16.8%), prognostic forecasting (28/179, 15.6%), and explorative analysis of big data sets (10/179, 5.6%). The most frequent strengths of affordable wearables were validation, accuracy, and clinical certification (104/179, 58.1%).

Conclusions

Wearables showed an increasingly diverse field of application such as COVID-19 prediction, fertility tracking, heat-related illness, drug effects, and psychological interventions; they also included underrepresented populations, such as individuals with rare diseases. There is a lack of research on wearable devices in low-resource contexts. Fueled by the COVID-19 pandemic, we see a shift toward more large-sized, web-based studies where wearables increased insights into the developing pandemic, including forecasting models and the effects of the pandemic. Some studies have indicated that big data extracted from wearables may potentially transform the understanding of population health dynamics and the ability to forecast health trends.

Objectively measured physical activity in patients with heart failure: a sub-analysis from the HF-Wii study

AIMS

Physical activity (PA) is important in patients with heart failure (HF) to improve health outcomes. The adherence to PA is low, and therefore, novel approaches are necessary to increase PA. We aimed to determine the difference in PA in patients with HF who have access to exergaming compared to patients who received motivational support and to explored predictors of a clinically relevant change in non-sedentary time between baseline and 3 months.

METHODS AND RESULTS

In total, 64 patients (mean age 69 ± 9 years, 27% female) wore an accelerometer 1 week before and 1 week after the intervention. Data were analysed using logistic regression analysis. Patients spent 9 h and 43 min (±1 h 23 min) during waking hours sedentary. There were no significant differences in PA between patients who received an exergame intervention or motivational support. In total, 30 of 64 patients achieved a clinically relevant increase in non-sedentary time. Having grandchildren [odds ratio (OR) 7.43 P = 0.03], recent diagnosis of HF (OR 0.93 P = 0.02), and higher social motivation (OR 2.31 P = 0.03) were independent predictors of a clinically relevant increase of non-sedentary time.

CONCLUSION

Clinicians should encourage their patients to engage in alternative approaches to improve PA and reduce sedentary habits. Future exergaming interventions should target individuals with chronic HF who have low social motivation and a low level of light PA that may benefit most from exergaming. Also (non-familial), intergenerational interaction is important to enabling patients in supporting patients in becoming more active.

The importance of physical activity and cardiorespiratory fitness for patients with heart failure

The present review highlights current research on the importance of PA and fitness for patients with heart failure and recommendations with respect to heart failure phenotypes and special populations. Furthermore, the evidence for various exercise types and intensities/doses as an "exercise prescription", are discussed. The strong association between heart failure and traditional risk factors, physical inactivity and low fitness, underlines the importance of regular PA and exercise for prevention and treatment of heart failure. This is illustrated by cardiac stiffness which typically accelerates in middle-life and could be reversed by aerobic exercise. In patients with HFpEF, regular PA counteracts many of the changes observed, both metabolic and functional. Indeed, exercise-based cardiac rehabilitation has received a class 1A recommendation in current guidelines [1], in order to improve functional capacity, quality of life and lower the risk of rehospitalization. An individually tailored plan based on risk stratification, clinical assessment and cardiopulmonary exercise testing is encouraged before initiation of exercise training in patients with heart failure. In general, a combination of aerobic exercise and resistance training protocols is recommended (Table 1) [2], preferably throughout life. More studies are needed, regarding the role of PA and exercise in specific populations, such as frail patients with heart failure.

Relationships Between Objectively Measured Physical Activity, Exercise Capacity, and Quality of Life in Older Patients With Obese Heart Failure and Preserved Ejection Fraction

BACKGROUND

The relationship between physical activity (PA), exercise capacity, and quality of life (QOL) in obese heart failure with preserved ejection fraction is poorly understood.

METHODS AND RESULTS

This was an ancillary study to a clinical trial. Accelerometers were used to measure light PA, moderate to vigorous PA, total PA, PA energy expenditure, and steps. Peak VO₂, exercise time, and 6-minute walk distance, as well as QOL measures were obtained. Pearson correlations were performed to examine relationships between PA, exercise capacity, and QOL. Patients (n = 58) were 68.0 ± 5.7 years old, 78% female, 59% White, and obese (body mass index 39.1 ± 6.1 kg/m²). Patients had low levels of objectively measured PA as well as decreased exercise capacity and poor QOL. Light PA (r = 0.32, P = .014) and steps per day (r = 0.30, P = .022) were modestly correlated with peak VO₂. All PA variables were modestly correlated with exercise time (r = 0.33-0.49, all P < .02) and 6-minute walk distance (r = 0.25-0.48, all P < .01). None of the PA variables were correlated with QOL.

CONCLUSIONS

PA variables were modestly correlated with measures of exercise capacity and were not significantly correlated with QOL. Our findings indicate that PA, exercise capacity, and QOL assess different aspects of the patient experience in older obese patients with heart failure with preserved ejection fraction.

Physical Functioning in Heart Failure With Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is increasingly prevalent, yet interventions and therapies to improve outcomes remain limited. There has been increasing attention towards the impact of comorbidities and physical functioning (PF) on poor clinical outcomes within this population. In this review, we summarize and discuss the literature on PF in HFpEF, its association with clinical and patient-centered outcomes, and future advances in the care of HFpEF with respect to PF. Multiple PF metrics have been demonstrated to provide prognostic value within HFpEF, yet the data are less robust compared with other patient populations, highlighting the need for further investigation. The evaluation and detection of poor PF provides a potential strategy to improve care in HFpEF, and future studies are needed to understand if modulating PF improves clinical and/or patient-reported outcomes. LAY SUMMARY: • Patients with heart failure with preserved ejection fraction (HFpEF) commonly have impaired physical functioning (PF) demonstrated by limitations across a wide range of common PF metrics.• Impaired PF metrics demonstrate prognostic value for both clinical and patient-reported outcomes in HFpEF, making them plausible therapeutic targets to improve outcomes.• Clinical trials are ongoing to investigate novel methods of detecting, monitoring, and improving impaired PF to enhance HFpEF care.Heart failure with preserved ejection fraction (HFpEF) is increasingly prevalent, yet interventions and therapies to improve outcomes remain limited. As such, there has been increasing focus on the impact of physical performance (PF) on clinical and patient-centered outcomes. In this review, we discuss the state of PF in patients with HFpEF by examining the multitude of PF metrics available, their respective strengths and limitations, and their associations with outcomes in HFpEF. We highlight future advances in the care of HFpEF with respect to PF, particularly regarding the evaluation and detection of poor PF.

Clinical and demographic correlates of accelerometer-measured physical activity in participants enrolled in the OPTIMISE HFpEF study

AIMS

This study aimed to measure physical activity (PA) in participants with suspected heart failure with preserved ejection fraction (HFpEF) and assess associations between PA and participant characteristics.

METHODS AND RESULTS

Adults with presumed HFpEF were recruited and received diagnostic evaluation and clinical assessment. Physical activity was objectively measured using accelerometers over 7 days. To examine predictors of PA, a best subset analysis was used, with the optimal model defined as that with the lowest Bayesian information criterion. One hundred and twenty-four participants with presumed HFpEF who had valid accelerometer data were included in this study. Seventy-six were confirmed by a cardiologist as meeting the European Society of Cardiology diagnosis criteria for HFpEF. The median age of all participants was 80.1 years, and 47.4% were female. Patients spent most of each 24-h period at low-intensity PA and few or no durations at high-intensity PA, with lower activity for those with HFpEF. Gait speed was the best univariate correlate of activity levels (adjusted R2 0.29). The optimal model using best subsets regression included six variables and improved adjusted R2 to 0.47. In the model, lower levels of PA were associated with slower gait speed, lower levels of anxiety, higher levels of depression, past smoking history, a confirmed HFpEF diagnosis, and higher body mass index.

CONCLUSION

Participants demonstrated very low PA levels. The study has identified important patient characteristics associated with PA, which may help to identify those most in need of interventions. Notably, participants with confirmed HFpEF were more inactive than participants with other heart failure phenotypes.

ActiGraph and Short-term Heart Rate Variability Study Protocol: Amended for the COVID-19 Pandemic

BACKGROUND

ActiGraph accelerometry is widely used in nursing research to estimate daily physical activity. Heart rate variability (HRV), a measure of autonomic modulation, can be assessed in conjunction with the ActiGraph using a Polar H7 Bluetooth heart rate monitor. There is a paucity of nursing literature to guide nurse researchers' protocol development when using the ActiGraph to assess both physical activity and short-term HRV via its Bluetooth capabilities.

OBJECTIVES

The aim of this study was to describe a standardized research ActiGraph and HRV (ActiGraph HRV) protocol for an ongoing randomized controlled trial to measure physical activity and short-term HRV in patients with ischemic heart disease who report hopelessness.

METHODS

We outline the study protocol for the standardization of reliable and rigorous physical activity and HRV data collection using the ActiGraph wGT3X-BT and Polar H7 Bluetooth heart rate monitor, and data analysis using ActiLife and Kubios software programs.

RESULTS

Sixty-four participants enrolled in the randomized controlled trial to date, and 45 (70.3%) have completed or are actively participating in the study. Heart rate variability data have been collected on 43 of the 45 participants (96%) to date. During the first data collection time point, 42 of 44 participants (95.5%) wore the ActiGraph for a minimum of 5 valid days, followed by 28 of 31 participants (90.3%) and 25 of 26 participants (96.2%) at subsequent data collection time points. The intraclass correlation for physical activity in this study is 0.95 and 0.98 for HRV.

DISCUSSION

Revisions to the protocol were successfully implemented at the onset of the COVID-19 pandemic for data collection using social distancing. The protocol was additionally amended in response to an unanticipated problem with ActiGraph battery life using Bluetooth technology. Use of the ActiGraph HRV protocol has led to a reliable and rigorous measurement of physical activity and HRV for patients with ischemic heart disease who report hopelessness in this randomized controlled trial.

CONCLUSION

We provide an ActiGraph HRV protocol that can be adapted as a model in the development of ActiGraph HRV protocols for future nursing research in community and home-based settings while maximizing social distancing in the current and future pandemics.

Sympathetic neural responses in heart failure during exercise and after exercise training

The sympathetic nervous system coordinates the cardiovascular response to exercise. This regulation is impaired in both experimental and human heart failure with reduced ejection fraction (HFrEF), resulting in a state of sympathoexcitation which limits exercise capacity and contributes to adverse outcome. Exercise training can moderate sympathetic excess at rest. Recording sympathetic nerve firing during exercise is more challenging. Hence, data acquired during exercise are scant and results vary according to exercise modality. In this review we will: (1) describe sympathetic activity during various exercise modes in both experimental and human HFrEF and consider factors which influence these responses; and (2) summarise the effect of exercise training on sympathetic outflow both at rest and during exercise in both animal models and human HFrEF. We will particularly highlight studies in humans which report direct measurements of efferent sympathetic nerve traffic using intraneural recordings. Future research is required to clarify the neural afferent mechanisms which contribute to efferent sympathetic activation during exercise in HFrEF, how this may be altered by exercise training, and the impact of such attenuation on cardiac and renal function.

Advances in accelerometry for cardiovascular patients: a systematic review with practical recommendations

Aims

Accelerometers are becoming increasingly commonplace for assessing physical activity; however, their use in patients with cardiovascular diseases is relatively substandard. We aimed to systematically review the methods used for collecting and processing accelerometer data in cardiology, using the example of heart failure, and to provide practical recommendations on how to improve objective physical activity assessment in patients with cardiovascular diseases by using accelerometers.

Methods and results

Four electronic databases were searched up to September 2019 for observational, interventional, and validation studies using accelerometers to assess physical activity in patients with heart failure. Study and population characteristics, details of accelerometry data collection and processing, and description of physical activity metrics were extracted from the eligible studies and synthesized. To assess the quality and completeness of accelerometer reporting, the studies were scored using 12 items on data collection and processing, such as the placement of accelerometer, days of data collected, and criteria for non‐wear of the accelerometer. In 60 eligible studies with 3500 patients (of those, 536 were heart failure with preserved ejection fraction patients), a wide variety of accelerometer brands (n = 27) and models (n = 46) were used, with Actigraph being the most frequent (n = 12), followed by Fitbit (n = 5). The accelerometer was usually worn on the hip (n = 32), and the most prevalent wear period was 7 days (n = 22). The median wear time required for a valid day was 600 min, and between two and five valid days was required for a patient to be included in the analysis. The most common measures of physical activity were steps (n = 20), activity counts (n = 15), and time spent in moderate‐to‐vigorous physical activity (n = 14). Only three studies validated accelerometers in a heart failure population, showing that their accuracy deteriorates at slower speeds. Studies failed to report between one and six (median 4) of the 12 scored items, with non‐wear time criteria and valid day definition being the most underreported items.

Conclusions

The use of accelerometers in cardiology lacks consistency and reporting on data collection, and processing methods need to be improved. Furthermore, calculating metrics based on raw acceleration and machine learning techniques is lacking, opening the opportunity for future exploration. Therefore, we encourage researchers and clinicians to improve the quality and transparency of data collection and processing by following our proposed practical recommendations for using accelerometers in patients with cardiovascular diseases, which are outlined in the article.

Characterization of Sedentary Behavior in Heart Failure Patients With Arthritis

Background

Arthritis is one of the most common comorbidities in heart failure (HF) patients, and is associated with decreased activity levels. Few studies have examined sedentary behavior (SB) in HF patients with arthritis, and little is known about the factors that may influence SB in this population.

Methods

This is a retrospective, secondary analysis using data collected from a randomized control trial. SB was measured by the daily sedentary time collected by accelerometers. Structural equation modeling was performed to examine relationships between key concepts based on social cognitive theory, and elucidate the potential pathways by which demographic, clinical and sociobehavioral factors that influence SB.

Results

A total of 101 participants’ data were used for this analysis. Participants were mainly female (n = 64, 63%) with a mean age of 70 years (standard deviation (SD) = 12.2) and an average of 13 years of education (SD = 2.3). SB was highly prevalent at baseline (mean value: 21.0 h/day), 3 months (mean value: 20.6 h/day) and 6 months (mean value: 20.8 h/day) in study participants. Factors with statistically significant positive association with sedentary time include age and retirement, while significant negative association was found with current employment. HF self-care efficacy and behavior were also significantly associated with SB.

Conclusions

Most HF patients with arthritis in this study lived a sedentary lifestyle. Additional studies are needed to identify feasible and effective exercise programs for HF participants with arthritis.

Fear of Physical Activity, Anxiety, and Depression

Abstract. Background: Physical activity (PA) is recommended by heart failure treatment guidelines. Adherence to exercise prescriptions is low and not much is known about everyday PA in this patient group. Aims: This study describes objectively assessed everyday PA/sedentary behavior in men and women with chronic heart failure and examines associations of potential barriers for engaging in PA, namely fear of physical activity (FoPA), general anxiety, and depression, with indicators of PA and sedentary behavior. Method: In 61 outpatients with heart failure (67.5 ± 10.7 years of age) the impact of FoPA, trait anxiety, and depression on 6-day accelerometer measures was evaluated using linear regression models. Results: Sedentary behavior was prevalent in men and women alike, with lying down and sitting/standing as predominant activity classes during daytime. Men had higher PA energy expenditure (726 vs. 585 kcal/d, Cohen’s effect size d = 0.74) and walked up/down more often (0.21% vs. 0.12% of total PA, d = 0.56) than women. FoPA did not differ between sexes. FoPA, but not anxiety and depression, significantly and consistently predicted less walking up/down independent of covariates (β-values between −0.26 and −0.44, p-values < 0.024). Limitations: The self-selected sample included few women. Medical data were assessed via self-reports. Conclusion: FoPA, but not anxiety and depression, significantly and consistently predicted less walking up/down independent of covariates. These preliminary findings highlight FoPA as a barrier to everyday PA in patients with heart failure.

Training heart failure patients with reduced ejection fraction attenuates muscle sympathetic nerve activation during mild dynamic exercise

Muscle sympathetic nerve activity (MSNA) decreases during low-intensity dynamic one-leg exercise in healthy subjects but increases in patients with heart failure with reduced ejection fraction (HFrEF). We hypothesized that increased peak oxygen uptake (V̇o_2peak) after aerobic training would be accompanied by less sympathoexcitation during both mild and moderate one-leg dynamic cycling, an attenuated muscle metaboreflex, and greater skin vasodilation. We studied 27 stable, treated HFrEF patients (6 women; mean age: 65 ± 2 SE yr; mean left ventricular ejection fraction: 30 ± 1%) and 18 healthy age-matched volunteers (6 women; mean age: 57 ± 2 yr). We assessed V̇o_2peak (open-circuit spirometry) and the skin microcirculatory response to reactive hyperemia (laser flowmetry). Fibular MSNA (microneurography) was recorded before and during one-leg cycling (2 min unloaded and 2 min at 50% of V̇o_2peak) and, to assess the muscle metaboreflex, during posthandgrip ischemia (PHGI). HFrEF patients were evaluated before and after 6 mo of exercise-based cardiac rehabilitation. Pretraining V̇o_2peak and skin vasodilatation were lower (P < 0.001) and resting MSNA higher (P = 0.01) in HFrEF than control subjects. Training improved V̇o_2peak (+3.0 ± 1.0 mL·kg^-1·min^-1; P < 0.001) and cutaneous vasodilation and diminished resting MSNA (-6.0 ± 2.0, P = 0.01) plus exercise MSNA during unloaded (-4.0 ± 2.5, P = 0.04) but not loaded cycling (-1.0 ± 4.0 bursts/min, P = 0.34) and MSNA during PHGI (P < 0.05). In HFrEF patients, exercise training lowers MSNA at rest, desensitizes the sympathoexcitatory metaboreflex, and diminishes MSNA elicited by mild but not moderate cycling. Training-induced downregulation of resting MSNA and attenuated reflex sympathetic excitation may improve exercise capacity and survival.

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.