Cardiac Rehabilitation in Heart Failure: A Brief Review and Recommendations

The number of heart failure patients continues to increase for men and women. Our current medical therapy includes a variety of agents that can reduce morbidity and mortality. However, many patients remain limited, in part, due to deconditioning. Adding to the functional loss are the multiple hospitalizations and even recommendations from providers to maintain bed rest and avoid physical activity. The multiple studies involving conditioning and exercise for patients with heart failure have mostly shown improvements, not only in function but also in quality of life and other physiologic parameters that should be of benefit to these patients. The HF ACTION (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training) trial, which randomized 2,231 patients to a formal prescribed exercise or control, demonstrated the safety of aerobic training in this population. The benefits on the hard end points of mortality and hospitalizations were modest but significant when adjusted for prognostic factors. The guidelines currently recommend that activity be recommended in conjunction with medical therapy. A program can be adjusted to the patient’s need but should include intensity, frequency, and duration, as well as a guide to progression.     

Zinc Deficiency and Heart Failure: A Systematic Review of the Current Literature

Zinc is an essential micronutrient that impacts the cardiovascular system through modulation of oxidative stress. It is unknown whether zinc levels are affected in heart failure (HF), and whether the association, if present, is causal. A systematic search for publications that report coexisting zinc deficiency in patients with HF was performed to provide an overview of the pathophysiological and epidemiological aspects of this association (last search April 2019). Review of the literature suggests multiple potential pathophysiologic causes for zinc deficiency in HF as a result of impaired micronutrient consumption, hyper-inflammatory state, upregulation of the renin-angiotensin-aldosterone axis, diminished absorption, and hyperzincuria from HF medications. In a longitudinal study of patients with HF in the setting of intestinal malabsorption, there was partial cardiomyocyte and left ventricular ejection fraction recovery with intravenous selenium and zinc supplementation. Two randomized double-blind control trials evaluating micronutrient and macronutrient supplementation including zinc in patients with HF found improvement in echocardiographic findings compared with placebo. Two recently completed studies evaluated the role for zinc supplementation in 2 different HF populations: a trial of zinc supplementation in patients with non-ischemic HF, and a trial of micronutrient supplementation (including B vitamins, vitamin D, and zinc) in veterans with systolic dysfunction; the results of which are still pending. Several pathobiological pathways to link zinc deficiency with the development and deterioration of HF are presented. Preliminary clinical data are supportive of such an association and future studies should further investigate the effects of zinc supplementation on outcomes in patients with HF.     

超滤在心力衰竭治疗中的价值和展望

容量负荷过重是心力衰竭患者反复住院的主要原因,钠潴留是核心的病理生理环节。血液超滤是治疗液体潴留的“金标准”。现有证据表明超滤能改善心力衰竭转归,降低再住院率。现综述超滤治疗心力衰竭的机制、有效性、安全性、适应证以及未来的研究方向。     

The Role of Cardiac Rehabilitation in Reducing Major Adverse Cardiac Events in Heart Transplant Patients

BackgroundMethods for reducing major adverse cardiac events (MACE) in patients after heart transplantation (HTx) are critical for long-term quality outcomes.Methods and ResultsPatients with cardiopulmonary exercise testing prior to HTx and at least 1 session of cardiac rehabilitation (CR) after HTx were included. Exercise sessions were evaluated as ≥ 23 or < 23 sessions based on recursive partitioning. We included 140 patients who had undergone HTx (women: n = 41 (29%), age: 52 ± 12 years, body mass index: 27 ± 5 kg/m²). Mean follow-up was 4.1 ± 2.7 years, and 44 patients (31%) had a MACE: stroke (n = 1), percutaneous intervention (n = 5), heart failure (n = 6), myocardial infarction (n = 1), rejection (n = 16), or death (n = 15). CR was a significant predictor of MACE, with ≥ 23 sessions associated with a ∼ 60% reduction in MACE risk (hazard ratio [HR]: 0.42, 95% CI: 0.19–0.94, P = 0.035). This remained after adjusting for age, sex and history of diabetes (HR: 0.41, 95% CI: 0.18–0.94, P = 0.035) as well as body mass index and pre-HTx peak oxygen consumption (HR: 0.40, 95% CI: 0.18–0.92, P = 0.031).ConclusionsAfter adjustment for covariates of age, sex, diabetes, body mass index, and pre-HTx peak oxygen consumption, CR attendance of ≥ 23 exercise sessions was predictive of lower MACE risk following HTx. In post-HTx patients, CR was associated with MACE prevention and should be viewed as a critical tool in post-HTx treatment strategies.     

Benefits of Cardiac Rehabilitation in Heart Failure Patients According to Etiology: INCARD French Study

We investigated the impact of heart failure (HF) etiology on the outcome of cardiac rehabilitation (CR) assessed by functional and clinical parameters.Treatment of chronic HF requires multidisciplinary approaches with a recognized role for CR. INCARD is a French study aimed at evaluating the benefits of sustainable CR in coronary (C) and noncoronary patients (NC) treated and educated during a 24-month period of follow-up.Prospective, monocentric patients with HF underwent inpatient physical training followed by a home-based program. Evaluations were performed at inclusion, discharge, 3 months after discharge, and subsequently every 6 months over the 24 months of outpatient rehabilitation.A total of 147 HF patients with left ventricular ejection fraction (LVEF) <40 were admitted to the CR center, 63 accepted to join INCARD (29 C and 34 NC).Although the C participants C having both an echocardiographic LVEF and an initially lower peak VO2, inpatient rehabilitation improved all functional parameters. Only NC showed an improved LVEF during the first 3 months of outpatient-follow-up. The main outcome of the outpatient rehabilitation was a trend toward stabilization of clinical and laboratory parameters with no significant difference between C and NC.This study confirms the benefits of initial HF inpatient rehabilitation and encourages prolonged outpatient monitoring. The results on functional parameters suggest exercise training should be conducted regardless of the HF etiology.     

Right Ventricular Function and Beneficial Effects of Cardiac Rehabilitation in Patients With Systolic Chronic Heart Failure

Background

It has been recognized that a comprehensive cardiac rehabilitation (CR) program improves mortality in patients with chronic heart failure. On the other hand, the magnitude of the improvement in exercise capacity after CR differs among individuals. The aim of this study was to assess the echocardiographic determinants of responders to CR using preload stress echocardiography.

Heart Failure and Skilled Nursing Facilities: Review of the Literature

BackgroundAlmost one-fourth of older adults hospitalized with heart failure (HF) are discharged to skilled nursing facilities (SNFs). The purpose of this review was to evaluate knowledge about HF patients discharged to SNFs to provide a foundation for future studies.Methods and ResultsA search was conducted of Medline, CINAHL, PubMed, and Google Scholar. Key words were heart failure, congestive heart failure, skilled care, skilled nursing care, skilled nursing facilities, nursing home, postacute care, postacute services, and subacute care. Publications (n = 37) were reviewed and categorized into case studies, editorials, clinical care, evaluation projects, and data-based publications. Of 29 data-based publications, 6 were focused on factors associated with hospital readmission from postacute settings, 3 on trends in hospitalizations, 12 on hospital discharge to postacute services, 5 on rehabilitation services in postacute settings, 1 on cost, and 2 on interventions. Patients discharged to SNFs were at high risk for mortality and multiple hospitalizations. No HF-specific care or guidelines were found at SNFs. Only 1 study evaluated quality of life at SNFs.ConclusionsProspective studies are needed to evaluate the clinical condition of HF patients discharged to SNFs and the interventions they receive.     

心脏再同步化治疗在轻度心力衰竭患者中的临床应用研究进展

过去的十几年里,心脏再同步化治疗(CRT)被广泛地用于严重的心力衰竭患者。临床研究表明,CRT能明显改善重度心力衰竭患者症状和生活质量等,最新国际指南也将重度心力衰竭患者作为CRT治疗的I类适应证。但CRT在轻中度心力衰竭患者中的应用前景和疗效仍不是很清楚。现对CRT改善心功能的机制及其在轻度心力衰竭的临床应用和研究结果做一综述。     

心肌细胞自身抗体的研究进展

越来越多的研究表明，免疫反应参与了心力衰竭的发病，并且在患者的血清中检测到了特定的抗体，推测与心血管疾病相关的自身抗体可能参与心室重塑和／或心衰的病理生理过程。本文就心肌自身抗体在心力衰竭患者中的研究进展作一综述。     

Cardiac Resynchronization Therapy in Patients with Mild Heart Failure: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Objective  

This review aims at updating the results of cardiac resynchronization therapy (CRT) in mild heart failure patients, and investigating whether CRT can prevent or reverse heart failure progression in an earlier stage.