By Michael Salama, MD, FIT (Fellow in Training), and Alison L. Bailey, MD, FAACVPR, FACC | April 17, 2019

With an estimated 6.5 million currently living in the United States people with heart failure (HF) and more than 650,000 new cases diagnosed annually, HF is one of the most common and complicated cardiovascular disorders seen in the medical community¹. Nearly half of these cases represent HF with reduced ejection fraction (HFrEF; EF<40 percent).

It is well established that HF is a progressive disorder, and a staging system has been introduced to clarify therapies as well as prognosis². The first two stages (A and B) are not clinical HF but are an attempt to provide early identification of patients who are at risk for developing HF and thus can have preventative strategies employed. Stage A represents the presence of risk factors for HF but no structural changes of the heart. Stage B patients are asymptomatic but have structural changes of the left ventricle (LV) and/or impaired LV function. Stage C denotes patients with current or past symptoms of HF associated with underlying structural heart disease.

Stage D designates patients with refractory HF. Up to 10 percent of all heart failure patients are considered to have advanced heart failure, Stage D, which is a term that has overlapping definitions. According to the 2007 Heart Failure Society of America position statement, Stage D HF is “a stage where conventional treatments (guideline-directed drugs, devices, conventional surgery) are insufficient to control the patient’s symptoms, and advanced therapies (cardiac transplantation, mechanical circulatory support) or palliative therapies (inotropic infusions, ultrafiltration or peritoneal dialysis to control volume, or end-of-life comfort care) are needed”³. Despite the advancements in therapy for HF patients, the disorder is still associated with high morbidity and mortality. In a recent report from a large HF referral center, roughly one in four patients with Stage C HF progressed to Stage D HF or died within three years⁴. The outcomes in community centers are likely worse, since patients who are not deemed a candidate for advanced therapies may never be referred.

Cardiac Rehabilitation (CR) has been shown to improve survival, functional capacity and quality of life in cardiovascular disease patients in a dose-dependent manner^5-7. It has been indicated for stable HFrEF patients for many years. Now, new data is emerging of the role of CR in patients with both left ventricular assist devices (LVAD) and those who have received a cardiac transplant. A review of LVAD therapy and CR can be found here⁸.

It has been established that CR improves maximal oxygen consumption, peak heart rate, ventilatory capacity, autonomic function and quality of life in cardiac transplant patients who attend the program⁹. Long-term data regarding hard outcomes like morbidity and mortality for CR in cardiac transplant recipients, however, is sparse. A recent study showed that individuals who attended CR after cardiac transplant experienced a 29 percent lower one-year readmission risk than those who did not attend as well as the improvements in functional capacity and quality of life.

Cardiac rehab has been shown to improve symptoms and functional capacity in patients with continuous-flow LVADs¹⁰. A randomized study demonstrated that CR compared to usual care, provided a significant improvement in functional capacity (increased total treadmill time and increased leg strength) as well as a significant difference in health status (higher scores on the Kansas City Cardiomyopathy Questionnaire).  Recently, it was shown that CR attendance after implantation of an LVAD was associated with a 23 percent lower risk of one-year hospitalization as well as a 47 percent lower risk of mortality at one year¹¹.

The likelihood of attending CR varies among indications. Rates of initiation of CR in HF patients is <10 percent and ranges from 10-20 percent in patients post-acute myocardial infarction and percutaneous coronary intervention, up to 35 percent in post coronary artery bypass grafting^12-15. Only about 30 percent of patients who receive an LVAD participate in CR while initiation rates of 55 percent have been reported post cardiac transplant^9,11. While this number marks the highest initiation rate among the various CR indications, it is still surprisingly low when the cost of CR is considered relative to the global cost of care for a cardiac transplant recipient.

Some of the reported barriers to CR participation in cardiac transplant and LVAD patients are similar to those of other groups and include work responsibilities, distance to the nearest CR center, availability of transportation, caregiver responsibilities and social anxiety⁹. Additionally, time to CR initiation remains a challenge in the United States and may be a larger barrier in these groups. It has been demonstrated that median wait time from referral to initiation of CR is 42 days for overall referrals and for every day of delay after discharge, a 1 percent reduction in participation rates for CR are seen¹⁶. Longer wait time to start CR has also been significantly associated with less improvement in cardiopulmonary fitness, body fat percentage, resting heart rate, and poorer attendance to CR classes and completion rate¹⁷. Reported median times from hospital discharge to the first CR appointment are 54 days in transplant patients and 83 days for LVAD patients^9,11.

Heart or heart-lung transplant is currently an indicated diagnosis for CR. VAD implantation is not currently a covered indication for CR, however, most VAD recipients are eligible for CR under the HFrEF indication, which covers patients with stable, chronic HF and a LVEF of <35 percent.

What does this mean for the CR professional?

Patients with HFrEF are increasing in our population and receive proven benefit from CR. Once these patients have progressed to advanced therapies like LVAD or transplant, CR can be useful to improve outcomes, functional capacity and quality of life as well as readmission and mortality. Cardiac rehab centers should develop protocols for patients receiving an LVAD or cardiac transplant that encourage early utilization of this proven non-pharmacologic therapy.


References:

1. Benjamin, EJ et al. Heart Disease and Stroke Statistics—2017 Update. A Report from the American Heart Association. Circulation 2017;  135: e146-e603.
2. Hunt SA, Abraham WT, Chin MH, et al. 2009 Focused Update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2009; 119: e391-479.
3. Crespo-Leiro MG, Metra M, Lund LH, et al. Advanced Heart Failure: A Position Statement of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2018; 20: 1505-1535.
4. Kalogeropoulous AP, Samman-Tahhan A, Hedley JS, et al. Progression to Stage D Heart Failure Among Outpatients With Stage C Heart Failure and Reduced Ejection Fraction.  J Am Coll Cardiol HF 2017; 5: 528-537.
5. Dugmore LD, Tipson RJ, Phillips MH, et al. Changes in cardiorespiratory fitness, psychological wellbeing, quality of life, and vocational status following a 12 month cardiac exercise rehabilitation programme. Heart 1999; 81: 359-66.
6. Anderson L, Oldridge N, Thompson DR, et al. Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis. J Am Coll Cardiol 2016; 67:1–12.
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