Exercise and Heart Failure

Exercise and Heart FailureExercise and Heart Failure

Tami Ward MS, APRN, NP-C, CHFNOctober 10, 2013

I have no conflict of interest

ObjectivesObjectives

Discuss reduced ejection fraction(HFrEF) and preserved ejection fraction (HFpEF) heart failure

Examine the role and recommendations of exercise training in heart failure (HF)

Identify barriers and strategies to overcome these barriers in the HF population

Two Types of HF Two Types of HF

The definition of HF has now expanded to: a. HF with reduced ejection fraction

(HFrEF, EF≤40%) b. HF failure with preserved ejection fraction (HFpEF EF ≥50%) c. HFpEF, borderline (EF 41-49%) d. HFpEF, improved (EF >40%)

Definition of Heart FailureDefinition of Heart FailureClassification Ejection

FractionDescription

I. Heart Failure with Reduced Ejection Fraction (HFrEF)

≤40% Also referred to as systolic HF. Randomized clinical trials have mainly enrolled patients with HFrEF and it is only in these patients that efficacious therapies have been demonstrated to date.

II. Heart Failure with Preserved Ejection Fraction (HFpEF)

≥50% Also referred to as diastolic HF. Several different criteria have been used to further define HFpEF. The diagnosis of HFpEF is challenging because it is largely one of excluding other potential noncardiac causes of symptoms suggestive of HF. To date, efficacious therapies have not been identified.

a. HFpEF, Borderline 41% to 49% These patients fall into a borderline or intermediate group. Their characteristics, treatment patterns, and outcomes appear similar to those of patient with HFpEF.

b. HFpEF, Improved >40% It has been recognized that a subset of patients with HFpEF previously had HFrEF. These patients with improvement or recovery in EF may be clinically distinct from those with persistently preserved or reduced EF. Further research is needed to better characterize these patients.

ACCF/AHA 2013 HF Guidelines JAC 2013 5 June (E-Pub online)

Important points regarding HF Important points regarding HF managementmanagement

The number of patients with HF, as well as the cost to treat patients with HF, is expected to increase in the future.

All causes of HF must be evaluated, with consideration of multigenerational family histories and genetic testing.

Risk factors need to be continually addressed when managing a patient with HF: hypertension, lipid disorders, obesity, diabetes mellitus, tobacco use, and known cardiotoxic agents.

There is a clear mortality benefit from using guideline-directed medical therapy.

Important points regarding HF Important points regarding HF managementmanagement

Anticoagulation should not be used in patients with chronic HFrEF with no risk factors (atrial fibrillation, thromboembolic event, or cardioembolic source).

Aim for control of systolic and diastolic blood pressures, as well as volume status, to treat HFpEF.

Re-evaluate patients with left ventricular EF ≤35%, New York Heart Association class II-IV, left bundle branch block, and a QRS ≥150 ms for cardiac resynchronization therapy.

HF education, dietary restrictions, and exercise training should be provided for all patients to enhance self-care.

A HF multidisciplinary team, including a palliative care team, should be involved when treating patients with advanced HF.

Classification of Heart FailureClassification of Heart FailureACCF/AHA Stages of HF NYHA Functional Classification

A At high risk for HF but without structural heart disease or symptoms of HF.

None

B Structural heart disease but without signs or symptoms of HF.

I No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF.

C Structural heart disease with prior or current symptoms of HF.

I No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF.

II Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF.

III Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF.

IV Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest.

D Refractory HF requiring specialized interventions.


STAGE AAt high risk for HF but without structural heart

disease or symptoms of HF

STAGE BStructural heart disease

but without signs or symptoms of HF

THERAPYGoals· Control symptoms· Improve HRQOL· Prevent hospitalization· Prevent mortality

Strategies· Identification of comorbidities

Treatment· Diuresis to relieve symptoms

of congestion· Follow guideline driven

indications for comorbidities, e.g., HTN, AF, CAD, DM

· Revascularization or valvular surgery as appropriate

STAGE CStructural heart disease

with prior or current symptoms of HF

THERAPYGoals· Control symptoms· Patient education· Prevent hospitalization· Prevent mortality

Drugs for routine use· Diuretics for fluid retention· ACEI or ARB· Beta blockers· Aldosterone antagonists

Drugs for use in selected patients· Hydralazine/isosorbide dinitrate· ACEI and ARB· Digoxin

In selected patients· CRT· ICD· Revascularization or valvular

surgery as appropriate

STAGE DRefractory HF

THERAPYGoals· Prevent HF symptoms· Prevent further cardiac

remodeling

Drugs· ACEI or ARB as

appropriate · Beta blockers as

appropriate

In selected patients· ICD· Revascularization or

valvular surgery as appropriate

e.g., Patients with:· Known structural heart disease and· HF signs and symptoms

HFpEF HFrEF

THERAPYGoals· Heart healthy lifestyle· Prevent vascular,

coronary disease· Prevent LV structural

abnormalities

Drugs· ACEI or ARB in

appropriate patients for vascular disease or DM

· Statins as appropriate

THERAPYGoals· Control symptoms· Improve HRQOL· Reduce hospital

readmissions· Establish patient’s end-

of-life goals

Options· Advanced care

measures· Heart transplant· Chronic inotropes· Temporary or permanent

MCS· Experimental surgery or

drugs· Palliative care and

hospice· ICD deactivation

Refractory symptoms of HF at rest, despite GDMT

At Risk for Heart Failure Heart Failure

e.g., Patients with:· Marked HF symptoms at

rest · Recurrent hospitalizations

despite GDMT

e.g., Patients with:· Previous MI· LV remodeling including

LVH and low EF· Asymptomatic valvular

disease

e.g., Patients with:· HTN· Atherosclerotic disease· DM· Obesity· Metabolic syndrome orPatients· Using cardiotoxins· With family history of

cardiomyopathy

Development of symptoms of HF

Structural heart disease


Signs and Symptoms in HF Signs and Symptoms in HF patientspatients

Exercise intolerance due to fatigue and dyspnea most prominent

Other S & S:◦Paroxysmal nocturnal dyspnea◦Orthopnea, ◦Edema◦Worsening dyspnea with exertion or at rest◦Tachycardia◦Change in weight

Role of Exercise Training in HFRole of Exercise Training in HF

Current Guidelines 2013:◦Class I Exercise training (or regular physical activity) is

recommended as safe and effective for patients with HF who are able to participate to improve functional status

(Level of Evidence: A)

◦Class IIa Cardiac rehabilitation can be useful in clinically

stable patients with HF to improve functional capacity, exercise duration, HRQOL, and mortality.

(Level of Evidence: B)

Benefits with exercise and cardiac Benefits with exercise and cardiac rehabilitationrehabilitation

Improvement in exercise capacity after exercise training due to peripheral adaptations (increased oxygen extraction)

Improvement in quality of lifeReduced hospitalizations and mortalityImproved endothelial functionReduction in catecholamine levels

Risks to exerciseRisks to exercise

Three major risk factors: age, presence of heart disease and intensity of exercise◦Lowest incidence: walking, cycling and treadmill walking

◦Least active patients are higher risk◦In HF patients, most common events include: post-exercise hypotension, atrial and ventricular arrhythmias and worsening HF symptoms

Relative Contraindications to Relative Contraindications to Exercise in Stable HF PatientsExercise in Stable HF Patients

Weight gain > 3 lb in 1-3 daysDrop in systolic BP with exercise

(marked/symptomatic)NYHA IV (can exercise selective patients)Complex ventricular arrhythmias Resting heart rate ≥ 100 bpmPre-existing unstable co-morbidities

Absolute Contraindications to Absolute Contraindications to Exercise with Stable HF Exercise with Stable HF PatientsPatients

Progressive worsening of exercise intolerance (dyspnea at rest)

Ischemia is suspectedSevere AS or severe regurgitant

valvular diseaseAcute systemic illnessNew onset afibAcute pericarditis/myocarditis/embolism

Exercise RecommendationsExercise Recommendations

Aerobic activity such as walking or cycling

Frequency – 3-5 days a week or most days

Intensity – 55-80% heart rate reserve with perceived exertion (11-14)

Duration of each session – start at 5 minutes if needed and progress to 30-60 minutes

Exercise RecommendationsExercise Recommendations

Cycling◦Allows low level workloads◦Easily reproducible◦May be safer with orthopedic or balance problems

WalkingSwimmingyogaInterval trainingFlexibility and resistance training

Barriers and possible Barriers and possible solutionssolutions

Patient relatedSocial and economicHealthcare team/systemCondition and Therapy related

Patient related BarriersPatient related Barriers

Older ageLow level of educationLow socio-economic statusMinority statusAnxiety and depressionLogistical problemsLack of motivation, lack of insight into

benefits and lack of time

European Journal of Heart Failure (2012) 14, 451-458

Social and Economic BarriersSocial and Economic Barriers

Lack or resources and supportLack of reimbursementTransportation concerns


Healthcare team/system barriersHealthcare team/system barriers

Lack of expertise with heart failureLack of capacityLack of referralLack of education on the importance of

exercise


Condition and Therapy Related Condition and Therapy Related BarriersBarriers

Severity of symptomsLevel of disabilityRate of disease progressionImpact of co-morbidities


Recommendations to overcome Recommendations to overcome barriersbarriers

Patient related◦Optimize heart failure management; manage

co-morbid conditions ◦Discuss activity at each visit to rehab◦Assess preferred mode of exercise◦Education; engage patient as partner in

exercise◦Screen for depression

Recommendations to overcome Recommendations to overcome barriersbarriers

System and therapy related◦Have referral system in place◦Educate providers

Case studyCase study

74 year-old male with history of coronary artery disease; inferior STEMI 2010 (unsuccessful PCI)complicated with cardiogenic shock and VT; initial EF 25%; received single chamber ICD

◦Hypertension◦Hyperlipidemia◦Osteoarthritis◦ Ischemic cardiomyopathy◦insomnia

Case StudyCase Study

Social History◦Never used tobacco products◦No alcohol and substance abuse◦Retired lawyer

Family History◦Father died of sudden death – age 60

Surgical History◦Cataracts; ICD implant

Case studyCase study

Medications◦Aspirin 81mg daily◦Carvedilol 12.5mg twice daily◦Lisinopril 20mg daily (now on study drug – NEP

inhibitor)◦Furosemide 40mg twice daily◦Potassium 20mEq daily◦Simvastatin 40mg daily◦Meloxicam as needed◦Trazadone 25mg at bedtime◦Nitroglycerine 0.4mg as needed

Case StudyCase StudyExercise history

◦Swimmer in high school◦Lifeguard at the Officers Club Pool in the Army

Medical Core◦Cardiac rehab after STEMI◦Resumed swimming after MI U.S. Master’s Senior Olympics

9 Gold medals in Kansas Senior Meet - September ‘13

“My Doctor said if I hadn’t been in such good physical shape from swimming it very likely would have been a fatal heart attack. Swimming or any kind of exercise saves lives”.

In SummaryIn Summary

Find strategies to get patients referred and enrolled in your cardiac rehabilitation program

Use this opportunity to give disease specific education to the HF patients

Prescribing exercise for HF patients is similar to patients without HF

Partner with your providers to help keep these patients out of the hospital with close surveillance of their symptoms.

[email protected]@Alegent.org

Thank You!

Exercise and Heart Failure

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