Elsevier

Journal of Cardiac Failure

Volume 22, Issue 12, December 2016, Pages 1015-1022
Journal of Cardiac Failure

Review Article
Growing Relevance of Cardiac Rehabilitation for an Older Population With Heart Failure

https://doi.org/10.1016/j.cardfail.2016.10.010Get rights and content

Abstract

Cardiac rehabilitation (CR) is a comprehensive lifestyle program that can have particular benefit for older patients with heart failure (HF). Prevalence of HF is increasingly common among older adults. Mounting effects of cardiovascular risk factors in older age as well as the added effects of geriatric syndromes such as multimorbidity, frailty, and sedentariness contribute to the high incidence of HF as well as to management difficulty. CR can play a decisive role in improving function, quality of life, symptoms, morbidity, and mortality, and also address the idiosyncratic complexities of care that often arise in old age. Unfortunately, the current policies and practices regarding CR for patients with HF are limited to HF with reduced ejection fraction and do not extend to HF with preserved ejection fraction, which is likely undercutting its full potential to improve care for today's aging population. Despite the strong rationale for CR on important clinical outcomes, it remains underused, particularly among older patients with HF. In this review, we discuss both the potential and the limitations of contemporary CR for older adults with HF.

Section snippets

HF in Older Adults: Competing Challenges of Management

Longevity is increasing. Average length of life has increased 30 years since 1900.10 Men and women are now more likely to live to old age, many after recovering from diseases/events that would have once ended their lives at a younger age. The result is a growing population of older adults with a constellation of medical complexities and vulnerabilities that represent a relatively new clinical challenge. This burgeoning population is uniquely predisposed to HF. HFrEF tends to increase because of

The Limits of the Evidence

HF-ACTION was a landmark trial that purportedly showed efficacy and safety of an aerobic exercise training program for a wide range of HFrEF patients. However, not only was there implicit selection bias in a study population that volunteered for a 2- to 3-year training trial, but HF-ACTION's conclusions regarding life-prolonging benefits of exercise training were only significant after adjustments for baseline characteristics strongly predictive of the trial's clinical endpoints27 (ie, exercise

Benefits—Physical Function and Exercise Capacity

HF patients have lower baseline oxygen consumption that healthy controls.29 A major benefit of exercise training in patients with stable HF is improved exercise capacity (maximum amount of sustainable physical exertion) that has been observed in both duration as well as peak oxygen uptake. Having greater exercise capacity allows one to be active at higher intensity or for a longer time and to also perform activities of daily living at a relatively lower percentage of overall fitness (which is

Posthospitalization Syndrome

Krumholz described posthospitalization syndrome as “an acquired, transient period of vulnerability.” This vulnerability is as much due to the acute illness prompting the hospitalization as it is to the broader allostatic and physiologic stresses of being hospitalized, which leaves patients with an impaired ability to response to health-related stressors.13 It constitutes a disproportionate risk for older patients with HF, especially among those with recurrent hospitalization and the

HFpEF

As adults live longer, HFpEF is becoming the dominant form of HF in the expanding senior population. Thus, while CMS was well-intended in basing CR eligibility on HF-ACTION trial data, this essentially overlooked the likely benefits of CR for HFpEF. While there is no equivalent large multicenter trial to HF-ACTION for HFpEF, multiple small studies have demonstrated the safety and utility of exercise training to improve functional capacity in older patients with HFpEF.67 Although HFpEF was once

Risks Associated with CR

For many years, there were entrenched concerns that exercise training might provoke harmful ventricular remodeling, particularly among those patients with HFrEF. Multiple trials have addressed this issue. A meta-analysis of randomized trials of exercise training attests to this large body of literature and confirms that aerobic exercise does not worsen ventricular remodeling. In fact, exercise training is likely to reverse ventricular remodeling in HFrEF73 with beneficial effects. Similarly,

Underutilization of CR

Despite the compelling benefits of CR and the widespread endorsement of its use, CR is vastly underused among patients with CHD.81 A recent study found only a 10% referral rate for patients after hospitalization for HF to CR from hospitals in the Get With the Guidelines database.82 Although this report predated the recent CMS decision to extend CR coverage to HFrEF, the enrollment of older patients into CR remains low even for diagnoses that have been approved for years,81 reflecting multiple

Challenges

Numerous challenges still remain to maximizing the use of CR for older adults with HF. For patients with HFrEF, the guidelines and reimbursement structure exists; however, there is still a common lack of understanding of all that CR can accomplish, particularly among candidates who are old and frail. For patients with HFpEF, there is a lack of large trials to substantiate CR benefits, despite a multitude of small studies that suggest compelling benefits and therapeutic rationale for a disease

Conclusions

Benefits of CR for HF include reduced mortality and morbidity, but also improved exercise capacity, QOL, symptoms, and mood—parameters that may be particularly important to older patients. CR is also particularly useful in addressing additional complexities of care for patients with advanced age, including multimorbidity, polypharmacy, and falling risks. Although CR is underused, particularly among older adults, it has the potential to greatly improve important clinical outcomes for patients

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    Funding: Dr. Schopfer is supported by the National Center for Advancing Translational Sciences of the NIH under Award Number KL2TR000143. Dr. Forman is supported in part by NIA grants P30 AG024827 and 1R56AG051637-01A1, PCORI grant IH-1304678, and VA Rehabilitation Research and Development grant F0834-R.

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