Review ArticleGrowing Relevance of Cardiac Rehabilitation for an Older Population With Heart Failure
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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2020, Nursing Clinics of North AmericaCitation Excerpt :HF prevalence is expected to increase to 8 million adults by the year 2030, with direct costs in the United States expected to reach $69.8 billion.38 Adults with HF frequently report poor exercise tolerance, reduced QOL, depression, and recurrent hospitalizations.39,40 Guidelines from the American College of Cardiology/American Heart Association (AHA) task force for the management of HF provide recommendations for pharmacologic treatment of HF with reduced ejection fraction (HFrEF; <45%) or those with HF with preserved ejection fraction (HFpEF; ≥45%), along with management of important comorbidities.37
Never Too Old for Cardiac Rehabilitation
2019, Clinics in Geriatric MedicineCitation Excerpt :As a result, by the year 2050, it is estimated that 1 in 4 Americans will be older than 65 years old, with close to 5% of the population being older than 85 years.3,4 This exponential increase in the population of older adults, colloquially termed the “silver tsunami,” presents a challenge to the health care system, as their medical complexities and age-related decline can lead to clinical outcomes that are less well aligned to standards established for younger adults, as well as associated increases in health care utilization and costs.5 Cardiovascular disease (CVD) is a chronic illness for which age is a risk factor.
Cardiac Rehabilitation to Optimize Medication Regimens in Heart Failure
2019, Clinics in Geriatric MedicineCitation Excerpt :Cardiac rehabilitation (CR) was recently approved by the Centers for Medicare & Medicaid Services for management of HF patients and provides a multifaceted secondary prevention program that combines a supervised exercise program with education and counseling to encourage lifelong health and fitness, improve self-care, facilitate self-efficacy, and ultimately improve clinical outcomes and quality of life.17 Given its comprehensive nature and patient-centered focus,18 CR has the potential to enhance several other aspects of chronic disease management, such as diet, lifestyle, and stress management, and presents a remarkable opportunity to address medication optimization as a port of an expanded model of CR care. Because most CR programs target enrollment shortly after a cardiac event when changes in HF medications are common, CR provides an ideal platform for important medication management interventions.17
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.