Lifestyle intervention improves daily steps but not functional capacity in HFrEF
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Key takeaways:
- A lifestyle intervention did not increase functional capacity in patients with heart failure with reduced ejection fraction vs. usual care.
- The intervention did increase daily step count and activity time.
PHILADELPHIA — In patients with HF with reduced ejection fraction, a lifestyle intervention improved daily steps by 25%, but that did not translate to improvement in functional capacity, according to the results of the WATCHFUL trial.
For WATCHFUL, presented at the American Heart Association Scientific Sessions and simultaneously published in Circulation, Jan Belohlavek, MD, PhD, professor of medicine, second department of medicine – department of cardiovascular medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, and colleagues randomly assigned 202 patients with HFrEF (mean age, 65 years; 23% women; mean left ventricular ejection fraction, 32.5%; mean 6-minute walk distance at baseline, 385 m) from six Czech HF centers to the intervention or a control group.
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“The objective of our trial was to determine if a 6-month lifestyle walking intervention combining self-monitoring and regular phone counseling improves functional capacity assessed by the 6-minute walk test in HFrEF compared with usual care,” Belohlavek said during a presentation.
The intervention group received an activity tracker (Garmin vívofit) and monthly phone counseling from research nurses who encouraged behavioral change techniques such as self-monitoring, goal setting and action planning to increase daily step count. The control group received the usual care.
All patients were on guideline-directed medications and none exceeded 450 m in 6-minute walk distance at baseline.
At 6 months, the primary outcome of change in 6-minute walk distance did not differ between the groups (adjusted between-group difference, 7.4 m; 95% CI, –8 to 22.7; P = .345), Belohlavek said during the presentation.
However, he said, at 6 months, increase in daily step count was greater in the intervention group than the control group (adjusted between-group difference, 1,420; 95% CI, 749-2,091), as was increase in daily minutes of moderate to vigorous physical activity (adjusted between-group difference, 8.2; 95% CI, 3-13.3).
There were no differences between the groups in the following secondary outcomes: N-terminal pro-B-type natriuretic peptide, high-sensitivity C-reactive protein, ejection fraction, anthropometric measures, depression score, self-efficacy, quality of life and survival risk score.
“We think further research is needed to understand the disconnect between increased activity and functional outcomes,” Belohlavek said during the presentation.
In a related editorial published in Circulation, David J. Whellan, MD, MHS, senior associate provost for clinical research and associate dean for clinical research at Thomas Jefferson University and Sidney Kimmel Medical College in Philadelphia, wrote: “The WATCHFUL study showed that promoting activity, even without a wearable device, can increase activity. In addition, patients are open to coaching and behavior modification programs. We also learned that just asking patients with HFrEF to be active and increase their step count without focusing on the volume of exercise (intensity and time exercising) will not really move the dial.”
In a discussant presentation, Jennifer T. Thibodeau, MD, MHCS, medical director of heart failure and ECMO at UT Southwestern Medical Center, said: “The duration of follow-up for this less intense exercise program may not have been sufficient in the smaller WATCHFUL trial to see improvement. ... A longer duration of follow-up might be necessary to see a clinical benefit. We need to determine appropriate duration and intensity of exercise that will lead to benefit. We also need to improve adherence to exercise interventions after the study program is done. We need to determine appropriate outcomes. Perhaps for these shorter studies, quality of life is enough. ... What we’re going to end up finding is that we need to tailor an individualized exercise regimen for each patient. There is not going to be a one-size-fits-all for exercise interventions.”
References:
- Vetrovsky T, et al. Circulation. 2023;doi:10.1161/CIRCULATIONAHA.123.067395.
- Whellan DJ. Circulation. 2023;doi:10.1161/CIRCULATIONAHA.123.067588.
Perspective
Back to TopMatthew Belanger, MD, and Lili A. Barouch, MD
The American College of Cardiology and the AHA recommend regular physical activity or exercise training (class 1A) for patients with stage C HF to improve functional capacity and quality of life. While structured exercise-based programs (often in the context of cardiac rehabilitation) have been shown to improve these domains, the impact of lifestyle-based physical activity interventions that can be more easily incorporated into daily life has not been well studied. This is an important area of investigation, as there continue to be significant gaps in the utilization of cardiac rehabilitation in patients with HF, and rigorous exercise prescriptions may be difficult to sustain over the long term.
In the WATCHFUL trial, a 6-month walking intervention in stable patients with HFrEF did not result in increased functional capacity as measured by the 6-minute walk test. As noted by the investigators, a lifestyle-based walking intervention may not be of sufficient volume or intensity to translate into changes in functional capacity in patients with HFrEF. This is not entirely surprising based on what we know from prior studies. In the landmark HF-ACTION randomized trial published in 2009, a relatively rigorous exercise prescription including three 30-minute aerobic activity sessions weekly, targeting 70% of heart rate reserve, only resulted in a modest increase in 6-minute walk test after 3 months.
Although the WATCHFUL trial was neutral with regard to its primary outcome, the intervention did result in a 25% increase in daily step count (1,420 steps per day) and an increase in moderate to vigorous physical activity of roughly 8 minutes per day. This is a notable improvement above baseline physical activity level, and it is encouraging that a relatively simple intervention utilizing an activity tracker and phone counseling was able to elicit this lifestyle change.
The ongoing 12-month follow-up of the WATCHFUL trial will shed light on whether the increase in daily step count is sustainable using a home-based intervention, and more importantly, whether we actually see an increase in functional capacity over a longer time period. However, given that structured cardiac rehabilitation programs are the most effective physical activity intervention for increasing functional capacity in patients with HF thus far, it is important that we continue to focus on strategies to improve cardiac rehabilitation enrollment and adherence rates.
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Belohlavek J, et al. FS.06. Exercise is life (and death) - Approaches in athletes, arrhythmias and heart failure. Presented at: American Heart Association Scientific Sessions; Nov. 11-13, 2023; Philadelphia.
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