Long-Term Follow-Up of Very Old Heart Failure Patients Enrolled in a Trial of Exercise Training

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.

Exercise-Based Interventions to Enhance Long-Term Sustainability of Physical Activity in Older Adults: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Exercise is a form of physical activity (PA). PA is an important marker of health and quality of life in older adults. The purpose of this study was to conduct a systematic review of the literature to assess the effect of exercise-based interventions on an at least six-month follow up PA measure, and to describe the specific strategies implemented during the intervention to strengthen the sustainability of PA in community-dwelling 65+ year-old adults. We registered and conducted a systematic review and meta-analysis (PROSPERO: CRD42017070892) of randomized clinical trials (RCT). We searched three electronic databases during January 2018 to identify RCT assessing any type of exercise-based intervention. Studies had to report a pre-, post-, and at least 6-month post-intervention follow-up. To be included, at least one PA outcome had to be assessed. The effect of exercise-based interventions was assessed compared to active (e.g., a low-intensity type of exercise, such as stretching or toning activities) and non-active (e.g., usual care) control interventions at several time points. Secondary analyses were conducted, restricted to studies that reported specific strategies to enhance the sustainability of PA. The intervention effect was measured on self-reported and objective measures of time spent in PA, by means of standardized mean differences. Standardized mean differences of PA level were pooled. Pooled estimates of effect were computed with the DerSimonian–Laird method, applying a random effects model. The risk of bias was also assessed. We included 12 studies, comparing 18 exercise intervention groups to four active and nine non-active control groups. Nine studies reported specific strategies to enhance the long-term sustainability of PA. The strategies were mostly related to the self-efficacy, self-control, and behavior capability principles based on the social cognitive theory. Exercise interventions compared to active control showed inconclusive and heterogeneous results. When compared to non-active control, exercise interventions improved PA time at the six-months follow up (standardized mean difference (SMD) 0.30; 95%CI 0.15 to 0.44; four studies; 724 participants; I² 0%), but not at the one- or two-years follow-ups. No data were available on the mid- and long-term effect of adding strategies to enhance the sustainability of PA. Exercise interventions have small clinical benefits on PA levels in community-dwelling older adults, with a decline in the observed improvement after six months of the intervention cessation.

Cardiac rehabilitation and physical activity: systematic review and meta-analysis

Objective

To undertake a systematic review and meta-analysis to assess the impact of cardiac rehabilitation (CR) on physical activity (PA) levels of patients with heart disease and the methodological quality of these studies.

Methods

Databases (MEDLINE, EMBASE, CENTRAL, CINAHL, PsychINFO and SportDiscus) were searched without language restriction from inception to January 2017 for randomised controlled trials (RCTs) comparing CR to usual care control in adults with heart failure (HF) or coronary heart disease (CHD) and measuring PA subjectively or objectively. The direction of PA difference between CR and control was summarised using vote counting (ie, counting the positive, negative and non-significant results) and meta-analysis.

Results

Forty RCTs, (6480 patients: 5825 CHD, 655 HF) were included with 26% (38/145) PA results showing a statistically significant improvement in PA levels with CR compared with control. This pattern of results appeared consistent regardless of type of CR intervention (comprehensive vs exercise-only) or PA measurement (objective vs subjective). Meta-analysis showed PA increases in the metrics of steps/day (1423, 95% CI 757.07 to 2089.43, p<0.0001) and proportion of patients categorised as physically active (relative risk 1.55, 95% CI 1.19 to 2.02, p=0.001). The included trials were at high risk of bias, and the quality of the PA assessment and reporting was relatively poor.

Conclusion

Overall, there is moderate evidence of an increase in PA with CR participation compared with control. High-quality trials are required, with robust PA measurement and data analysis methods, to assess if CR definitely leads to important improvements in PA.

Long-term myocardial adaptations after cardiac rehabilitation in heart failure: a randomized six-year evaluation using magnetic resonance imaging

OBJECTIVE

To assess exercise capacity and left ventricular function using magnetic resonance imaging (MRI) among patients with chronic heart failure randomized to a residential rehabilitation programme at baseline and six years after participation.

DESIGN

Randomized controlled study.

SETTING

Residential cardiac rehabilitation centre and community hospital.

INTERVENTION

One month of intensive exercise and risk reduction therapy including educational sessions, a low-fat diet, and 2 hours of individually prescribed exercise daily. Control subjects received usual care. Subjects were evaluated at baseline, after completing the one-month residential programme and six years later.

SUBJECTS

From an original study group of 50, 16 patients (8 exercise, 8 controls) with chronic heart failure were alive and available for evaluation after six years.

MAIN MEASURES

Cardiopulmonary exercise test responses and ventricular size and function using MRI.

RESULTS

Peak Vo(2) was 20.0 and 12.4% higher after the rehabilitation programme and six years later, respectively, whereas minimal changes were observed among controls. Left ventricular mass and volumes tended to decrease among subjects in the exercise group, whereas left ventricular mass and volumes tended to increase among control subjects after six years. Ejection fraction increased approximately 20% in both groups.

CONCLUSION

Six years after participation in a concentrated residential rehabilitation programme, exercise capacity was preserved and no significant changes were observed in ventricular size or function. These findings provide further support for exercise rehabilitation in chronic heart failure.

A systematic review of community-based health interventions on depression for older adults with heart disease

PURPOSE

This systematic review examined the effectiveness of community-based heart-health interventions on depression outcomes among homebound elderly (64 years and older) with heart disease.

DESIGN AND METHODS

A comprehensive literature search and meta analysis was performed to evaluate randomized controlled trials examining outpatient or home-based interventions. Methodological quality was assessed by standard criteria developed by the Cochrane Collaborative Initiative.

RESULTS

Fifteen studies met our inclusion criteria and all measured depression outcomes. Studies differed in scope and methodological rigor and sample sizes varied widely. Problems in treatment fidelity and masking of group assignment were noted. Great variability was found in depression outcomes due to the differences in methodology and intervention. Five studies reported significant treatment effect on depression; three of those employed home-based interventions and two were outpatient-clinic interventions. Ten studies were included in the meta analysis and the effect sizes (ESs) ranged from -0.39 (in favor of control group) to 0.65 (in favor of treatment group). The mean weighted ES was 0.11 and six studies showed positive ESs.

IMPLICATIONS

Mixed evidence for community-based heart disease interventions on depression outcomes was found. Future research should include sub-analysis of ESs of interventions on depression outcomes by different demographic characteristics of the study sample, common depression outcome measures, and different follow-up periods.

Adherence to angiotensin-converting-enzyme inhibitors and illness beliefs in older heart failure patients

AIMS

Patient beliefs about heart failure (HF) may be important determinants of adherence. This study assessed levels of adherence to angiotensin-converting-enzyme inhibitors (ACEI) and examined whether beliefs about HF were associated with adherence to ACEI.

METHODS AND RESULTS

Fifty-eight patients with chronic stable HF (mean age 80.2 years SD +/- 4.6, 43% female) were recruited from two outpatient clinics in Dundee, UK. The Illness Perception Questionnaire-Revised was used to assess beliefs about HF. Adherence to ACEI was assessed by measuring serum levels of angiotensin-converting enzyme (sACE). Adherence to ACEI (defined as sACE <5 U/L) was 72%. Beliefs about the time-line of HF and the consequences of HF accounted for 19% of the variability in adherence to ACEI in this sample. Heart failure patients who believed that their illness had a more chronic (longer term) time frame and had beliefs about the greater consequences of HF on their lives were less likely to adhere to ACEI.

CONCLUSION

Adherence to ACEI is sub-optimal. Beliefs about HF appear to be associated with objectively measured adherence to ACEI. Future studies should attempt to identify beliefs that consistently predict adherence and examine whether modifying these beliefs can increase adherence to HF medications.

Long-term effects of a group-based high-intensity aerobic interval-training program in patients with chronic heart failure

Studies on the long-term effects of exercise training programs on functional capacity and the quality of life in patients with chronic heart failure (CHF) are sparse. The aim of this study was to evaluate the long-term effects of group-based, high-intensity interval training on functional capacity and the quality of life in 80 patients with stable CHF (mean age 70.1 +/- 7.9 years) in New York Heart Association classes II to IIIB. Patients were randomized to either an exercise group (n = 40) or a control group (n = 40). The mean ejection fractions at baseline were 31 +/- 8% in the exercise group and 31 +/- 1% in the control group. The exercise group exercised twice a week for 4 months in addition to 4 consultations with a CHF nurse. Six-minute walking distance, workload and exercise time on a cycle ergometer test, and the quality of life were measured at baseline and 4 and 12 months after enrollment. After 4 months, functional capacity (6-minute walking distance +58 vs -15 m, p <0.001) and the quality of life (Minnesota Living With Heart Failure Questionnaire score +10 vs -1 point, p <0.005) improved significantly in the exercise group compared with the control group. After 12 months, the improvements were still significant in the exercise group compared with the control group for all parameters (6-minute walking distance +41 vs -20 m, p <0.001; workload +10 vs -1 W, p = 0.001; exercise time +53 vs -6 seconds, p = 0.003; quality of life +10 vs -6 points, p = 0.003). In conclusion, the results support the implementation of a group-based aerobic interval training program to improve long-term effects on functional capacity and the quality of life in patients with CHF.