REHAB-HF: Rehabilitation program improves physical function in older adults with HF
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Older adults hospitalized for acute HF who participated in an early, tailored 12-week rehabilitation program had better outcomes compared with those receiving standard care, according to results of the REHAB-HF trial.
For the trial, presented at the American College of Cardiology Scientific Session and published in The New England Journal of Medicine, the researchers enrolled 349 hospitalized patients with HF aged 60 to 99 years (51% women; 53% with HF with preserved ejection fraction; 97% frail or prefrail). The patients were assigned to the intervention, which consisted of the usual care plus a program focusing on strength, balance, mobility and endurance in which progression of intensity and types of exercises performed based on performance level, or to an attention control group, which consisted of phone calls and the usual care alone.
“Our hypothesis was that in frail, older patients, hospitalized for acute decompensated HF, an innovative, early transitional, tailored, progressive, multidomain, rehab intervention will improve physical function and reduce hospitalizations,” Dalane W. Kitzman, MD, professor of cardiovascular medicine and geriatrics/gerontology at Wake Forest School of Medicine, said in a presentation.
In the intervention group, the patient retention rate was 82% and the rate of adherence to the sessions was 78%, according to the researchers.
When researchers adjusted for baseline Short Physical Performance Battery score and other baseline characteristics, the primary outcome of the least-squares mean score on the Short Physical Performance Battery at 3 months was 8.3 in the intervention group compared with 6.9 in the control group (mean between-group difference, 1.5; 95% CI, 0.9-2; P < .001). Kitzman said during the presentation that the treatment effect was relatively consistent across prespecified subgroups.
At 3 months, compared with the control group, the intervention group had greater improvements in 6-minute walk distance (P = .007), modified Fried Frailty Criteria (P = .028), Kansas City Cardiomyopathy Questionnaire score (P = .007) and Geriatric Depression Scare score (P = .013), Kitzman said during the presentation.
“At 6 months, 83% of intervention participants reported regular home exercise, which suggests behavioral change, a prerequisite for long-term adherence,” Kitzman said during the presentation.
According to the researchers, at 6 months, the rates of rehospitalization for any cause were 1.18 in the intervention group and 1.28 in the control group (rate ratio = 0.93; 95% CI, 0.66- 1.19).
Researchers observed that there were 21 deaths in the intervention group and 16 in the control group, for rates of 0.13 and 0.1, respectively (rate ratio = 1.17; 95% CI, 0.61-2.27).
“At 6 months, 83% of intervention participants reported regular home exercise, which suggests behavioral change, a prerequisite for durable behavioral change,” Kitzman said during the presentation.
The results presented by Kitzman and colleagues provide a compelling argument for the adoption of exercise rehabilitation as standard care, even for elderly, frail patients with acute heart failure,” Stefan D. Anker, MD, professor in the Berlin-Brandenburg Center for Regenerative Therapies and the department of cardiology at Charité University in Berlin, Germany, and Andrew J.S. Coats, DM, professor of medicine at the University of Warwick, Coventry, United Kingdom, wrote in a related editorial in NEJM.
References:
- Anker S, et al. N Engl J Med. 2021;doi:10.1056/NEJMe2106140.
- Kitzman DA, et al. N Engl J Med. 2021;doi:10.1056/NEJMoa2026141.
Perspective
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James Januzzi Jr., MD, FACC, FESC
REHAB-HF provides immediately actionable option for our most vulnerable patients with HF, specifically this multifactorial approach to CV rehab. It has a clear, rapid and substantial impact on performance that can be seen as soon as 3 months after randomization.
So, although small, the study sends an important message to us all that the intervention could benefit patients that are at the highest likelihood for a poor outcome with HF, including older patients, patients from underprivileged socioeconomic status, as well as patients with HF and preserved ejection fraction.
Such treatment is not a medication, it’s exercise — strength, balance, mobility — that can improve multiple domains of function. It’s really an important finding.
Perspective
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Javed Butler, MD, MPH, MBA, FACC, FAHA
Previous HF trials have generally tended to exclude older frail patients with advanced or complex multimorbidity burden. This unfortunately affects the generalizability of the results to a group of patients that are difficult to manage and are generally sicker and in need for interventions to improve their outcomes. In this respect, the REHAB-HF trial is important, as the patient population was largely frail or prefrail, had multiple comorbidities and had a mean age of 73 years. Of note, it was remarkable how well women and minority patients were enrolled in this trial.
Outcomes of patients with HF are particularly worse off after hospitalization. In this trial, the physical rehabilitation intervention was started during or soon after hospitalization for HF. The population was very sick with a mean 6-minute walk distance of less than 200 m and mean scores on the Kansas City Cardiomyopathy Questionnaire (KCCQ) of around 40. After the rehabilitation intervention, the Short Physical Performance Battery, which was 6 at baseline, showed a treatment effect of a mean difference in the overall score of 1.5 points, which is very meaningful. Also impressive were the differences in 6-minute walk distance (34 m) and gait speed (0.12 m/sec). KCCQ overall score difference between the two groups was 7.1 points, which is comparable or more than many other HF interventions.
The implication is that elderly patients hospitalized for worsening HF should be referred for physical rehabilitation. Larger future studies are needed to assess the impact physical rehabilitation on mortality.
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Kitzman D, et al. Joint American College of Cardiology/Journal of the American Medical Association Late-Breaking Clinical Trials. Presented at: American College of Cardiology Scientific Session; May 15-17, 2021 (virtual meeting).
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