Improving Patient Participation in Cardiac Rehabilitation for Heart Failure

Although exercise training was once thought to be contraindicated for patients with heart failure (HF), its benefits and safety in this population have since become well-established and supported by a range of research findings.¹ The HF-Action trial and subsequent studies have demonstrated improvements in functional capacity, clinical outcomes, psychological well-being, and quality of life (QOL) in patients with HF who participated in cardiac rehabilitation.^1,2 Accordingly, cardiac rehabilitation is a currently a Class 1 recommendation (Level of Evidence: A) in the American College of Cardiology/American Heart Association guidelines for HF management.³

“Patients with [HF] can experience improved exercise tolerance after multiple cardiac rehab sessions, and they may be able to perform daily activities with less dyspnea,” Joseph S. Alpert, MD, professor of medicine at the University of Arizona Sarver Heart Center in Tucson, Arizona, and author of a 2020 paper on the topic, told us in a recent interview.⁴ “Also, their understanding of their personal disease state can enable them to adhere more closely to the advised medical program, such as a low-salt diet, for example.”

Cardiac rehabilitation programs are typically led by a multidisciplinary team that may consist of a physician, nurses, exercise specialists, and dietitians, as well as mental health clinicians and pharmacist in some cases.  Although exercise training is a key part of this approach, cardiac rehabilitation is a comprehensive program that includes several additional components, such as psychosocial assessment; risk factor modification in terms of diet, smoking cessation, and stress management; and education and support regarding medication and program adherence. Along with improving outcomes, teaching patients how to self-manage their condition is an essential goal of a cardiac rehabilitation program.¹

In an article published in March in the Journal of the American College of Cardiology,the JACC Expert Panel provides detailed guidance on how to develop the various components of a cardiac rehabilitation  program, including an exercise prescription defining the frequency, intensity, time, and type of exercise tailored to each patient’s needs and abilities.¹ This prescription is often created by a cardiac rehabilitation  specialist in collaboration with the treating physician and may include aerobic exercise, resistance training, inspiratory muscle training, localized muscle training, or some combination thereof.

Aerobic exercise, such as treadmill walking, cycling, and swimming, particularly in the form of moderate continuous training, is the most frequently studied and used type of exercise in cardiac rehabilitation programs, and the other types may be substituted or added as appropriate.

“Aerobic training has been shown to reverse left ventricular remodeling in patients with HF who are clinically stable, results in improvements in aerobic capacity and peak oxygen uptake (VO₂), and modifies cardiovascular disease risk factors,” as stated in the JACC paper.¹

After the patient has initiated cardiac rehabilitation , the “effects of exercise prescription on functional capacity can be monitored by changes in symptoms, New York Heart Association (NYHA) functional class, [QOL], functional capacity measured by changes in VO₂ during peak exercise by cardiopulmonary exercise testing, or 6-min[ute] walk distance,” according to the authors.¹

Although the bulk of the data regarding the benefits of exercise training in HF pertain to patients with heart failure with reduced ejection fraction (HFrEF), emerging findings also show promising results for persons with heart failure with preserved ejection fraction (HFpEF). Evidence is currently insufficient to evaluate the efficacy and safety of exercise training in patients with advanced or stage D HF.¹

Despite the demonstrated benefits and cost-effectiveness of cardiac rehabilitation , this intervention remains underused in HF management (≤30% even with extensive support) for a variety of reasons, including patient-level factors such as logistical challenges and lack of perceived benefit.^1,4,5

“For some patients, it is difficult to get transportation to the cardiac rehab site, while for others, there is a healthy dose of denial of the seriousness of their disease and some patients truly do not understand what is going on,” said Alpert. “There may also be social concerns such as lack of family support and poverty.”

Emerging approaches provide alternatives to the traditional cardiac rehabilitation model when needed and may improve patient retention and satisfaction while extending support to individuals with geographic or other barriers. These include home-based rehabilitation as well as interventions incorporating telehealth, smartphones, wearable self-monitoring devices, and other forms of technology.¹

Issues related to healthcare policy and coverage decisions represent prohibitive factors for both patients and physicians, and a lack of physician awareness and knowledge of the benefits of cardiac rehabilitation  has been cited as an important contributor to the low patient participation rates.

“It is known that patient adherence would be higher with stronger physician endorsement,” according to the JACC expert panel.¹ “Clinicians, health care leaders, and payers should prioritize incorporating [cardiac rehabilitation] as part of the standard of care for patients with HF.”

Ongoing efforts are needed to elucidate and address the reasons for low patient participation in cardiac rehabilitation programs. Among other strategies, increasing the overall use of cardiac rehabilitation will require changes in payer coverage and health policy, including reduction of elimination of co-pays for cardiac rehabilitation, inclusion of cardiac rehabilitation under Medicaid essential services, and removal of the 6-week waiting period, as currently required by the Centers for Medicare & Medicaid Services.¹

Meanwhile, Alpert emphasized that “clinicians need to describe cardiac rehab with enthusiasm to their patients and point out the multiple benefits that result from this program.”

In addition, we “probably need to get the American Heart Association, the American College of Cardiology, and the World Heart Federation behind a campaign to increase participation in cardiac rehab for patients with heart failure as well as those with coronary artery disease,” Alpert added.

To further explore the benefits and barriers associated with the use of cardiac rehabilitation programs, we interviewed John Larry, MD, cardiologist, associate professor of clinical medicine at The Ohio State University Wexner Medical Center, and medical director of cardiology and cardiac rehabilitation at the Ohio State University Hospital East

What are some of the main benefits of cardiac rehab for patients with HF?

In the HF-Action study of patients with reduced left ventricular function, having an ejection fraction (EF) ≤35%, NYHA class II to IV symptoms and treated with optimal, guideline-based background HF therapy, exercise training provided a nonsignificant reduction in the risk for the primary endpoint of all-cause mortality or all-cause hospitalization and key secondary clinical endpoints.²

After adjustment of 4 important prespecified prognostic factors (exercise capacity, left ventricular ejection fraction (LVEF), Beck Depression Inventory score, history of atrial fibrillation or flutter), there was an 11% reduction in the incidence of the primary endpoint in the exercise training arm compared with the usual therapy arm.²

Subsequent evaluation of the trial demonstrated improvement in self-reported measures of QOL, and in exercise duration. Other smaller trials in patients with HFpEF have demonstrated increased functional capacity and improved QOL.¹

What are the likely reasons why cardiac rehab is underused despite such benefits? 

It has been reported that ≤30% of eligible candidates initiate cardiac rehab.¹ Many barriers have been identified. Failure of healthcare providers to refer patients may be because of lack of appreciation of the benefits that can be achieved or a sense a patient is too sick to achieve benefits. Patient difficulties in transportation, insurance coverage, financial issues, insufficient social support, family needs, or need to return to work can all contribute.

The lack of insurance coverage for many patients with HFpEF, expectation of a 6-week window of stabilization on medical therapy before starting, and high co-pays dissuade patients from participating. The viral pandemic provided another impediment, as many programs were shut down for a period of time and, even after reopening, patient fears of being exposed to the virus prevented many from attending cardiac rehab sessions. 

How can use of this resource be improved, and what are recommendations for clinicians about how to encourage this? 

Healthcare provider recognition of the improvement in QOL, increased patient independence and self-management, and the potential improvement in all-cause mortality and reduction in hospitalization rates can facilitate an increase in programmatic referrals. Having a referral process for appropriate patients being discharged from the hospital can improve enrollment. 

A careful assessment of potential barriers by the cardiac rehab program staff, with strategies to implement resources to reduce those barriers, can improve compliance. Continued discussions with healthcare insurers may help reduce financial barriers to participation. 

What should be next steps in terms of research in this area, and what are other remaining needs?

Additional trials are needed in those patients with HFpEF. Small studies have suggested benefits, but currently many third-party payers tend to cover only those patients with LVEF ≤35% who would have been candidates for enrollment in the HF-Action trial. Increased vaccination of the population will be critical to prevent consequence of COVID-19 and thus eliminate the fear for infection that is keeping many from initiating cardiac rehabilitation.

References

1. Bozkurt B, Fonarow GC, Goldberg LR, et al; ACC’s Heart Failure and Transplant Section and Leadership Council. Cardiac rehabilitation for patients with heart failure: JACC Expert Panel. J Am Coll Cardiol. 2021;77(11):1454-1469.
2. O’Connor CM, Whellan DJ, Lee KL, et al; HF-ACTION Investigators. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA. 2009;301(14):1439-1450.
3. Yancy CW, Jessup M, Bozkurt B, et al; American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62(16):e147-239.
4. Alpert JS. Cardiac rehabilitation: an underutilized class i treatment for cardiovascular disease. Am J Med. 2020;133(9):1005-1006.
5. Shields GE, Wells A, Doherty P, et al. Cost-effectiveness of cardiac rehabilitation: a systematic review. Heart. 2018;104:1403-1410.