Why are patients with heart failure not routinely offered cardiac rehabilitation?

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ORIGINAL A R T I C L E

Why are patients with heart failure not routinely offered cardiac rehabilitation? G. S. Bowman*, D. R. Thompson*, R. J. E Lewin~ *Research Fellow, School of Nursing," *Professorof Nursing, School of Nursing; ~ Professor of Rehabilitation, School of Medicine, University of Hull, Hull, UK SUMMARY. This paper considers the key issues of cardiac rehabilitation for patients with heart failure and discusses the current prospects of providing this service. The number of people with heart failure is rising, and the cost of treatment increases as symptoms become more pronounced. In addition, the quality of life for both the patient and partner deteriorates as the patient's condition worsens. It is now possible to include safely the patient with heart failure in the exercise component of cardiac rehabilitation, provided appropriate assessment is carried out. The patient with mild-to-moderate heart failure can expect to gain most from rehabilitation and, as a result, symptoms can be reduced and exercise tolerance and functional capacity improved. The psychosocial impact of heart failure is generally greater than that experienced by other cardiac patients, yet there is a dearth of research. Despite the possible benefits for this group of patients, entry to programmes may not be possible because of a lack of resources.

BACKGROUND

Most CR services adhere to a rigid structure offering little flexibility. They are largely hospitalbased, focused on exercise and education, and organized around a set protocol (Thompson et al. 1997). Some centres do not have exercise-testing equipment, encouraging the selection of safe, uncomplicated patients. Staff funding within programmes is variable, with estimates ranging from s 000 to s 000 in England and Wales (Gray et al. 1997), a situation which may well force poorly funded programme co-ordinators to restrict access and limit choice. Venues can also impose restrictions on service provision. Small gymnasia create their own logistical limitations to the size of the CR group; this, in turn, may also effect the total number of hours offered to patients for CR. For example, in a survey of a random sample of 25 centres in England and Wales, the volume of time offered to patients for exercise training varied between 4 and 16 (average 9.7) hours per week in total (Thompson & Bowman 1995). This demonstrates the variation in available exercise training for patients; it also indicates a degree of confusion over the perceived exercise requirements of patients. Given this inconsistent and confused picture, it can be assumed that much CR is not offered on the basis of individual assessment.

Cardiac rehabilitation (CR) programmes tend to be highly selective when enrolling patients, who are usually male, middle-aged and diagnosed as having an uncomplicated myocardial infarction (MI) (Thompson et al. 1997). Women, elderly people and those individuals with other cardiac diagnoses are either not offered or excluded from programmes. Historically, CR was initiated to help employed males recover from an MI and return to gainful employment. Only 'mild' or 'moderate' cases were the recipients of CR. Coronary vessels impaired because of atherosclerosis respond poorly to increased oxygen demands of the myocardium, with resultant ischaemia; patients with damaged myocardium and congestive heart failure may demonstrate impaired exercise tolerance (Balady & Weiner 1992). Despite this, patients who are frail or display cardiac symptoms can benefit most from an appropriate CR programme that includes exercise (Raffo et al. 1980; Port et al. 1981; Ehsani et al. 1986; Tristani et al. 1987; Coats et al. 1990; Hedback & Perk 1990; Todd & Ballantyne 1990; Ades et al. 1995; Kiilavuori et al. 1995).

Correspondenceto."GeraldS. BowmanMPhilRN, Research Fellow,Schoolof Health, Universityof Hull, Hull HU6 7RX, UK. Tel: +44 (0)1 482 466545; Fax: +44 (0)1 482 466699 187

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MORTALITY AND MORBIDITY

EXERCISE A N D H E A R T FAILURE

Improved control of heart failure, in addition to the ever-increasing age of the population, will add to the numbers of people disabled by heart failure. A gradual increase in the number of people with symptoms of heart failure is inevitable. The prevalence of heart failure rises with age: a study in the USA found that, in the population aged 25-54 years, heart failure was 1% and, in the 65-74 years age group, it was 4.5% (Schocken et al. 1992). In the USA, between 1977 and 1986, admission to hospital for patients with heart failure increased more than two-fold (Giles 1996), and heart failure treatment absorbs more health care resources as the incidence rises. The size of the problem seems to be in some dispute. In the USA, estimates of sufferers have varied between one and two million (Kannel et al. 1994), more than two million (Parmley 1996) and three million (Giles 1996). When using the New York Heart Association (NYHA) classification of heart failure, the percentage of patients declines as the severity of the condition increases (Giles 1996), thus:

The symptoms of heart failure are shortness of breath and fatigue, a result of back pressure to the lungs and forward pressure involving other vital organs. Despite these unpleasant symptoms, many patients with heart failure have a large potential for health gain and could participate in a CR programme (Thompson et al. 1996). Improved medical treatment with the consequent reduction in symptoms for CHD patients has created the potential for inclusion in exercise programmes of those previously considered unsuitable. Exercise training programmes are diverse and may vary in frequency, intensity and training mode (Weilenga et al. 1997). Of course there are serious limitations and potential problems in rehabilitating the patient with heart failure. The clinically complex patient is at a higher risk of developing complications during the period of increased planned exercise (Sullivan et al. 1988; Sobue et al. 1995). Patients with poor left ventricular function need careful supervision as their response is unpredictable, but they can and do improve with exercise training (Port et al. 1981; Tristani et al. 1987; Sullivan et al. 1988; Hedback & Perk 1990; Coats et al. 1990; Kiilavuori et al. 1995; Sobue et al. 1995). For example, a three-week exercise programme on the performance and economy of walking for patients with chronic heart failure who had marked exercise intolerance, showed that favourable metabolic changes and positive effects on the economy of motion could be achieved (Beneke & Meyer 1997). Careful assessment is essential before including patients with heart failure on a CR programme containing exercise. The main indicators to exercise capacity are abnormalities of diastolic filling pattern (Packer 1990; Davies et al. 1992). Cardiac pumping capability is predictive of the ultimate prognosis of patients in severe heart failure, whereas pumping reserve is a major determinant of exercise capacity (Tan 1987). Lactic acid increase and metabolic and blood flow abnormalities in skeletal muscle provoke heart failure symptoms (Dubach & Froelicher 1989). Exercise training may improve vasodilation and oxidation, and thereby reduce production of lactate (Dubach & Froelicher 1989; Sullivan & Cobb 1990; Belardinelli et al. 1995). Thus, patients with heart failure and normal cardiac output responses to exercise frequently improve their exercise endurance with physical training. Patients with severe haemodynamic dysfunction during exercise usually do not improve with exercise training (Wilson et al. 1996). Reviews of CR for heart failure patients acknowledge the emerging benefits, but advise caution, as some patients may develop adverse cardiac effects from exercise training (Dubach & Froelicher 1989; McKelvie et al. 1995). Most exercise studies utilize patients with mild-tomoderate heart failure (NYHA classes II and III).

NYHA NYHA NYHA NYHA

class class class class

I accounts for 50% of patients II accounts for 25% of patients III accounts for 15% of patients IV accounts for 10% of patients

Madsen et al. (1994), in an observational study of 190 consecutive heart failure patients, found the NYHA class and exercise variables gave strong prognostic information regarding mortality in combination with left ventricular ejection fraction, and they were mutually exclusive. The estimated survival rate after one year was 78% and after two years 68%, or a 32% mortality. The use of medical treatment such as ACE inhibitors can improve life expectancy. For example, patients with class IV heart failure randomly allocated to an enalapril treatment group had at 6 months a crude mortality of 40% lower and at one year 31% lower than the placebo group (The CONSENSUS Trial Study Group 1987). Franciosa et al. (1981) estimated mortality at one year to be 34%, at two years 59% and at three years 76% in patients with chronic left ventricular failure. Patients who had accompanying coronary heart disease (CHD) fared worse, with 45% of this group suffering sudden death. Patients with heart failure have a life expectancy of 4-5 years on average and, between 1985 and 1995, the age-adjusted death rate doubled (McKelvie et al. 1995). The prospects for heart failure patients may not be as comforting as the average suggested by McKelvie et al. (1995); Kannel et al. (1994) showed a median survival of 1.7 years in men and 3.2 years in women. In the UK, it has been estimated that the annual mortality is 10-20% in those with mild-tomoderate symptoms, and 40-60% in those with severe heart failure (Dargie et al. 1996). Coronary Health Care (1998) 2 (4), 187-192

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CR for patients with heart failure Randomized trials show these patients experience improvement in exercise tolerance (Coats et al. 1990; Coats et al. 1992; Scalvini et al. 1992), functional capacity (Koch et al. 1992; Belardinelli et al. 1995), peak oxygen consumption (Coats et al. 1990) and symptoms (Coats et al. 1990; Koch et al. 1992; Belardinelli et al. 1995). For the patient with mild-tomoderate heart failure (NYHA classes II and III), home-based exercise can provide the same gains as a hospital-based programme (Coats et al. 1990). Patients with very depressed cardiac function do not seem to improve their exercise tolerance (Scalvini et al. 1992). For most patients, aerobic capacity improvement is usually delayed for days or weeks after the initiation of therapy (Kao & Jessup 1994). According to McKelvie et al. (1995), the early promising results associated with exercise and heart failure require confirmation of feasibility, clinical benefit and safety in larger, long-term randomized trials. They also feel that the long-term effects of CR should impact on daily living activities, quality of life and ultimately mortality and morbidity.

QUALITY OF LIFE Assessment of health-related quality of life can provide additional clinical information on the course and outcome of heart failure that is not captured by traditional indices of clinical status (Konstam et al. 1996). According to Coats et al. (1994), a series of physiological changes caused by left ventricular dysfunction lead to skeletal myopathy creating exercise intolerance which in turn leads to reduced peripheral blood flow (the muscle hypothesis). It is suggested that specific muscle treatments may help in the management of chronic heart failure. Coats et al. (1994) argue that poor understanding of the physiological bases of the cardinal symptoms of heart failure has resulted in limited available therapeutic strategies. Consequently, Coats et al. (1994) believe that optimal treated patients, with a correspondingly low quality of life, require additional therapeutic intervention despite the lack of available objective measures and the increasing difficulty in reducing mortality for this group of patients. From a patient perspective, fatigue associated with sleep difficulties, chest pain, weakness and progressive dyspnoea are central to the patient's changed life (Friedman & King 1995). The effects of unabating symptoms may make the patient believe that their life situation cannot be influenced and become resigned (Martensson et al. 1997). Rideout and Montemuro (1986) have shown that hope and morale are related to social function, but not to physical variables or physical function in patients with chronic heart failure, suggesting that the more hopeful maintain their involvement with life. An important part of rehabilitating the chronically sick is maintaining hope for both the patient and family. 9 1998 Harcourt Brace & Co. Ltd

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From a health care perspective, the factors influencing quality of life include symptoms, loss of interest in the family, sexual difficulties, sleep disturbance, time off work and use of health services (Barnett 1991). There are quality of life measures available specifically for patients with heart failure. For example, a quality of life assessment battery has been developed for heart failure patients from a sub-study of the left ventricular dysfunction (SOLVD) trial; the assessments used were the six-minute walking test, dyspnoea scale, living with heart failure, physical limitations, psychological distress and health perceptions (Gorkin et al. 1993). Patients with NYHA classes III and IV disability describe their quality of life as significantly compromised, with depression predominating in their affective state (Dracup et al. 1992). Heart 9 failure patients experience significant mood disruption that appears to be greater than that reported by other cardiac patients, which is likely to influence their quality of life (Hawthorne & Hixon 1994). Drug treatment can influence quality of life. For example, pinnobendon (Rector & Cohn 1992) and enoxamine (Cowley & Skene 1994) have been shown to improve the quality of life in patients with heart failure. While ACE inhibitors may extend life, they appear to have little effect on improving healthrelated quality of life in patients with heart failure (Jenkinson et al. 1997). Further, one study using digoxin showed that the drug improved ejection fraction without any corresponding changes in exercise tolerance or quality of life (Kostis et al. 1994). In this study, the group receiving nonpharmacological therapy (which included graduated exercise training, structured cognitive therapy and dietary intervention) improved functional capacity, body weight and mood state. Immediate relatives are likely to be affected adversely by the patient's condition. Karmilovitch (1994) found significant increase in stress for the spouse of heart failure patients as the number of helping behaviours they perform increases; this stress is increased when they perceive difficulty in performing care-giving activities. Finally, a nurse-directed, multidisciplinary intervention (comprehensive education of patient and family, a prescribed diet, social service consultation, planning for early discharge, a review of medications and intensive follow-up) can improve the quality of life and reduce hospital use and medical costs for elderly patients with congestive cardiac failure (Rich et al. 1995).

THE COST OF HEART FAILURE Information concerned with the cost of heart failure is relatively sparse. The likely increase in life expectancy and numbers of people disabled by heart failure and the absence of cure makes reduction in the cost of treatment an important issue. Giles (1996) Coronary Health Care (1998) 2 (4), 187-192

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believes the main area for cost reduction in heart failure is a decrease in the number of patients readmitted to hospital. A New Zealand study estimates the cost of admitting patients with congestive heart failure to hospital as 1% of the total health budget (Doughty et al. 1995). In the UK, the readmission rate of one third of patients each year accounts for 66% of the total cost for treating heart failure (Andrews & Cowley 1995). Costs are exponential to the degree of disability imposed. Kulbertus (1987), in a Belgian study, broke down costs according to the NYHA classification system of patient assessment. The costs presented below take no account of insurance pay-out or lost production (there are approximately 60 Belgian Francs (BF) to the Pound Sterling): Class II: cost 32 000 BF per year per patient (seeing their practitioner twice a month, cardiologist four times a year, an electrocardiogram and chest X-ray taken, and an echocardiogram recorded every six months). Class III: cost 78 000 BF per year per patient (vasodilators, more practitioner visits and an increase in and repetition of investigations). Class IV: cost 1 000 000 BF (more hospital admissions). Readmissions to hospital can be reduced through the use of comprehensive, nurse-led interventions, which have been shown to cut medical costs (Rich et al. 1995; Sherman 1995). Clearly, any means of reducing disability and dependency could have a concomitant benefit in cost reduction.

DISCUSSION The increased knowledge of the efficacy of CR has led to the tentative inclusion of patients with heart failure in CR programmes. The benefits of rehabilitating patients with overt cardiac symptoms is not fully understood, nor have the rehabilitation needs of patients with heart failure been sufficiently defined. The objectives and principles of CR have been defined by the World Health Organization (1993), but, the programme and available skills may need to be reconsidered for the more complex heart failure patient; for example, the prime objective may be to reduce disability, or, alternatively to prepare the patient and family for death. Clearly the risks of physical exercise for this group of patients is greater than for symptom-free exercise programme participants. More careful assessment, prescription and supervision of exercise is required. The psychosocial needs of these patients can be assumed to be different from other groups of patients, as symptoms of dyspnoea and fatigue are often persistent and always distressing, and there is the possibility of increasing dependency on partners or family members, who may themselves experience coping difficulties. Finally, Coronary Health Care (1998) 2 (4), 187-192

there is the prospect of an uncomfortable death as the failing heart engorges other organs. Despite the human dimension of heart failure, there are relatively few research papers addressing this. Heart failure involves positive medical intervention up to the time of death. This positive approach to biological survival may have obscured the real consequences for the patient and family. This has led to a comparative lack of information on CR as a means of symptom/ disability reduction and even more so in the area of support requirements for the patient and family, especially the partner.

CONCLUSION The case for rehabilitation of the patient with heart failure is compelling. However, it is unlikely that CR centres in the UK have the resources to offer a rehabilitation plan that includes both exercise and educational counselling to the majority (85%) of heart failure patients who could benefit. The present state of CR suggests that limitations to entry are already imposed on patients with CHD who do not have medical complications (Thompson et al. 1997). Centres may therefore be reluctant to include patients who may be at a higher risk of complications during the exercise component of CR. Another salient factor is the environment in which studies are usually carried out. The supportive and focused nature of academic activity in the presence of research and support staff is vastly different from most CR programmes that rely on the lone programme co-ordinator. Logically and logistically, it may be in the interest of wider service provision of CR that patients with uncomplicated heart disease are initially offered community or self-care programmes. Patients with symptoms of heart disease may be more safely rehabilitated in a hospital environment where numbers are already restricted; it is also likely that optimum supervision and the technical support associated with the acute care environment will be immediately available. Consideration of less conventional approaches to symptom relief should be encouraged. Research into alternative therapies, like biofeedback techniques, may deserve more serious consideration for this group of patients. For example, in a controlled trial, patients in advanced heart failure assigned to biofeedbackrelaxation techniques showed increase in skin temperature, increase in cardiac output, decrease in systemic vascular resistance and a decrease in respiratory rate compared to controls (Moser et al. 1997). Thus, although it is feasible to rehabilitate the patient with heart failure, it may be wise to delay the wholesale inclusion of heart failure patients in CR until further evaluation has taken place. More information is needed before large numbers of patients with heart failure could be accommodated with confidence in UK CR programmes. Studies based in 9 1998 Harcourt Brace & Co. Ltd

CR for patients with heart failure non-academic CR environments are needed to determine whether the promising results obtained thus far are transferable into routine clinical practice. The needs of patients with heart failure are likely to be different from patients who have traditionally utilized CR programmes; therefore descriptive studies are needed to determine their real needs. Finally, costeffectiveness studies are required to determine outcomes and viability of rehabilitating patients with heart failure. REFERENCES Ades PA, Waldmann ML, Gillespie C 1995 A controlled trial of exercise training in older coronary patients. Journal of Gerontology 50A: M7-M11 Andrews R, Cowley AJ 1995 Clinical and economic factors in the treatment of congestive heart failure. Pharmacoeconomics 7: 119-127 Balady G J, Weiner DA 1992 Psychology of exercise in normal individuals and patients with coronary heart disease. In: Wenger NK, Hellerstein HK (eds) Rehabilitation of the Coronary Patient. Churchill Livingstone, New York, pp 103-t22 Barnett DB 1991 Assessment of quality of life. American Journal of Cardiology 67: 41C~14C Belardinelli R, Georgiou D, Scocco V, Barstow TJ, Purcaro A 1995 Low intensity exercise training in patients with chronic heart failure. Journal of the American College of Cardiology 26:975-982 Beneke R, Meyer K 1997 Walking performance and economy in chronic heart failure patients pre and post exercise training. European Journal of Applied Physiology 75:246-251 Coats AJS, Adamopoulos S, Meyer TE, Conway J, Sleight P 1990 Effects of physical training in heart failure. Lancet 335:63-66 Coats AJS, Adamopoulos S, Radaelli A e t al. 1992 Controlled trial of physical training in chronic heart failure: exercise performance, hemodynamics, ventilation, and autonomic function. Circulation 85:2119-2131 Coats AJS, Clark AL, Piepoli M, Volterrani M, Poole-Wilson PA 1994 Symptoms and quality of life in heart failure: the muscle hypothesis. British Heart Journal 72 (Suppl): $36-39 Cowley A J, Skene AM 1994 Treatment of severe heart failure: quantity or quality of life? A trial of enoximone. British Heart Journal 72:226-230 Dargie HJ, McMurray JJV, McDonagh TA 1996 Heart failure implications of the true size of the problem. Journal of Internal Medicine 239:309-315 Davies SW, Fussell AL, Jordan SL, Poole-Wilson PA, Lipkin DP 1992 Abnormal diastolic filling patterns in chronic heart failure - relationship to exercise capacity. European Heart Journal 13:749-757 Doughty R, Yee T, Sharpe N, MacMahon S 1995 Hospital admissions and deaths due to congestive heart failure in New Zealand, 1988-91. New Zealand Medical Journal 108: 473475 Dracup K, Walden JA, Stevenson LW, Brecht M-L 1992 Quality of life in patients with advanced heart failure. Journal of Heart and Lung Transplantation 1h 273-279 Dubach P, Froelicher VF 1989 Cardiac rehabilitation for heart failure patients. Cardiology 76:368-373 Ehsani AA, Biello DR, Schultz J, Sobel BE, Holloszy JO 1986 Improvement of left ventricular contractile function by exercise training in patients with coronary artery disease. Circulation 74:350-358 Franciosa JA, Park M, Levine TB 1981 Lack of correlation between exercise capacity and indexes of resting left ventricular performance in heart failure. American Journal of Cardiology 47:33-39 Friedman MM, King KB 1995 Correlates of fatigue in older women with heart failure. Heart and Lung 24:512-518 Giles T 1996 The cost-effective way forward for the management of the patient with heart failure. Cardiology 87:33-39 Gorkin L, Norvell NK, Rosen RC et al. 1993 Assessment of quality of life as observed from the baseline data of the

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