Gordon R. Reeves

Isosorbide mononitrate in heart failure with preserved ejection fraction

BACKGROUND Nitrates are commonly prescribed to enhance activity tolerance in patients with heart failure and a preserved ejection fraction. We compared the effect of isosorbide mononitrate or placebo on daily activity in such patients. METHODS In this multicenter, double-blind, crossover study, 110 patients with heart failure and a preserved ejection fraction were randomly assigned to a 6-week dose-escalation regimen of isosorbide mononitrate (from 30 mg to 60 mg to 120 mg once daily) or placebo, with subsequent crossover to the other group for 6 weeks. The primary end point was the daily activity level, quantified as the average daily accelerometer units during the 120-mg phase, as assessed by patient-worn accelerometers. Secondary end points included hours of activity per day during the 120-mg phase, daily accelerometer units during all three dose regimens, quality-of-life scores, 6-minute walk distance, and levels of N-terminal pro-brain natriuretic peptide (NT-proBNP). RESULTS In the group receiving the 120-mg dose of isosorbide mononitrate, as compared with the placebo group, there was a nonsignificant trend toward lower daily activity (-381 accelerometer units; 95% confidence interval [CI], -780 to 17; P=0.06) and a significant decrease in hours of activity per day (-0.30 hours; 95% CI, -0.55 to -0.05; P=0.02). During all dose regimens, activity in the isosorbide mononitrate group was lower than that in the placebo group (-439 accelerometer units; 95% CI, -792 to -86; P=0.02). Activity levels decreased progressively and significantly with increased doses of isosorbide mononitrate (but not placebo). There were no significant between-group differences in the 6-minute walk distance, quality-of-life scores, or NT-proBNP levels. CONCLUSIONS Patients with heart failure and a preserved ejection fraction who received isosorbide mononitrate were less active and did not have better quality of life or submaximal exercise capacity than did patients who received placebo. (Funded by the National Heart, Lung, and Blood Institute; ClinicalTrials.gov number, NCT02053493.).

Exercise Training as Therapy for Heart Failure Current Status and Future Directions

Despite a variety of pharmacological and device therapies for persons with chronic heart failure (HF), prognosis and quality of life (QOL) remain poor. The need for new effective strategies to improve outcomes for patients with HF is underscored by persistently high mortality, morbidity, healthcare use, and costs associated with HF, with >1 million US HF hospitalizations at an estimated direct and indirect cost in the US of

Prioritizing Functional Capacity as a Principal End Point for Therapies Oriented to Older Adults With Cardiovascular Disease: A Scientific Statement for Healthcare Professionals From the American Heart Association

40 billion in 2012.1 Exercise intolerance is a primary symptom in patients with chronic HF, both those with preserved ejection fraction (HFpEF) and reduced ejection fraction (HFrEF), and is a strong determinant of prognosis and of reduced QOL.2 Exercise training improves exercise intolerance and QOL in patients with chronic stable HFrEF, and has become an accepted adjunct therapy for these patients (Class B level of evidence) based on a fairly extensive evidence base of randomized trials, mostly small.3 The National Heart, Lung, and Blood Institute–funded Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training (HF-ACTION) trial compared an individualized, supervised, and home-based aerobic exercise program plus guideline-based pharmacological and device therapy with guideline-based therapy alone in persons with HFrEF. The exercise arm showed a modest reduction in cardiovascular hospitalizations and mortality and improved QOL.4,5 However, problems with adherence in the exercise arm probably dampened the potential benefit. This landmark study leaves several unanswered key questions, including the role of exercise dose; the relative benefit of different types of aerobic exercise, including high-intensity interval training (HIIT), and resistance, training relative to aerobic training; combination of exercise training with other therapies; optimization of adherence; benefit for older patients with HF, those with HFpEF or multiple comorbidities, and those with acute decompensated HF. The National Heart, Lung, and Blood Institute convened a working group of experts on June 11, …

Recent advances in cardiac rehabilitation.

Adults are living longer, and cardiovascular disease is endemic in the growing population of older adults who are surviving into old age. Functional capacity is a key metric in this population, both for the perspective it provides on aggregate health and as a vital goal of care. Whereas cardiorespiratory function has long been applied by cardiologists as a measure of function that depended primarily on cardiac physiology, multiple other factors also contribute, usually with increasing bearing as age advances. Comorbidity, inflammation, mitochondrial metabolism, cognition, balance, and sleep are among the constellation of factors that bear on cardiorespiratory function and that become intricately entwined with cardiovascular health in old age. This statement reviews the essential physiology underlying functional capacity on systemic, organ, and cellular levels, as well as critical clinical skills to measure multiple realms of function (eg, aerobic, strength, balance, and even cognition) that are particularly relevant for older patients. Clinical therapeutic perspectives and patient perspectives are enumerated to clarify challenges and opportunities across the caregiving spectrum, including patients who are hospitalized, those managed in routine office settings, and those in skilled nursing facilities. Overall, this scientific statement provides practical recommendations and vital conceptual insights.

Photoplethysmographic Signal to Screen Sleep-Disordered Breathing in Hospitalized Heart Failure Patients: Feasibility of a Prospective Clinical Pathway.

Purpose of review Cardiac rehabilitation has been established as an effective treatment for patients with ischemic heart disease for many years. Despite this, utilization remains low. The purpose of this article is to review the latest research on the benefit, utilization, and implementation of cardiac rehabilitation. Recent findings Recent research is supportive of the beneficial effects of cardiac rehabilitation in patients with heart failure as well as in older patients. Unfortunately, cardiac rehabilitation continues to be considerably underutilized with poor referral and enrollment rates. Implementing quality performance measures, automated referral systems, and the option of home-based cardiac rehabilitation for some patients may all help to increase participation. In addition, innovative exercise training regimens may help to enhance the beneficial effects of cardiac rehabilitation. Summary Cardiac rehabilitation appears beneficial in an increasing array of cardiovascular diseases. Ongoing efforts to improve its use are essential for optimal disease management.

Rehabilitation Therapy in Older Acute Heart Failure Patients (REHAB-HF) trial: Design and rationale

OBJECTIVES The purpose of this study was to evaluate the plethysmographic signal-derived oxygen desaturation index (ODI) as an inpatient screening strategy to identify sleep-disordered breathing (SDB) in patients with congestive heart failure (CHF). BACKGROUND SDB is highly prevalent among patients hospitalized with CHF but is widely underdiagnosed. We evaluated overnight photoplethysmography as a possible screening strategy for hospitalized patients with CHF. METHODS Consecutively admitted heart failure patients with high clinical suspicion of SDB and ODI ≥5 were offered outpatient polysomnography (PSG), which was completed within 4 weeks of discharge. PSG was considered positive if the apnea hypoxia index (AHI) was ≥5. A Bland-Altman plot was used to assess agreement between ODI and AHI. Receiver-operator characteristics were determined for ODI ≥5 and AHI ≥5. RESULTS A screening questionnaire identified 246 of 282 consecutive patients with positive symptoms for SDB. Of these patients, 105 patients were offered further evaluation and 86 had ODI ≥5 (mean ODI 17 ± 17). Among these 86 patients, 68 underwent outpatient PSG within 4 weeks of discharge. PSG showed that 64 (94%) had SDB, with a mean AHI of 28. Inpatient ODI correlated well with PSG-derived AHI. The area under the curve was 0.82 for AHI ≥5. The Bland-Altman plot revealed no major bias. Matthews correlation coefficient revealed that the optimal cut-off for ODI is 5. CONCLUSIONS Screening hospitalized patients with heart failure using targeted inpatient ODI identifies a cohort of patients with a high prevalence of SDB. Our screening strategy provides a potentially cost-effective method for early detection and treatment of SDB.

Evolving Role of Exercise Testing in Contemporary Cardiac Rehabilitation.

Background Acute decompensated heart failure (ADHF) is a leading cause of hospitalization in older persons in the United States. Reduced physical function and frailty are major determinants of adverse outcomes in older patients with hospitalized ADHF. However, these are not addressed by current heart failure (HF) management strategies and there has been little study of exercise training in older, frail HF patients with recent ADHF. Hypothesis Targeting physical frailty with a multi‐domain structured physical rehabilitation intervention will improve physical function and reduce adverse outcomes among older patients experiencing a HF hospitalization. Study design REHAB‐HF is a multi‐center clinical trial in which 360 patients ≥60 years hospitalized with ADHF will be randomized either to a novel 12‐week multi‐domain physical rehabilitation intervention or to attention control. The goal of the intervention is to improve balance, mobility, strength and endurance utilizing reproducible, targeted exercises administered by a multi‐disciplinary team with specific milestones for progression. The primary study aim is to assess the efficacy of the REHAB‐HF intervention on physical function measured by total Short Physical Performance Battery score. The secondary outcome is 6‐month all‐cause rehospitalization. Additional outcome measures include quality of life and costs. Conclusions REHAB‐HF is the first randomized trial of a physical function intervention in older patients with hospitalized ADHF designed to determine if addressing deficits in balance, mobility, strength and endurance improves physical function and reduces rehospitalizations. It will address key evidence gaps concerning the role of physical rehabilitation in the care of older patients, those with ADHF, frailty, and multiple comorbidities.

Hospitalizations and Prognosis in Elderly Patients With Heart Failure and Preserved Ejection Fraction: Time to Treat the Whole Patient.

Symptom-limited (maximal) exercise testing before cardiac rehabilitation (CR) was once an unambiguous standard of care. In particular, it served as an important screen for residual ischemia and instability before initiating a progressive exercise training regimen. However, improved revascularization and therapy for coronary heart disease has led many clinicians to downplay this application of exercise testing, especially because such testing is also a potential encumbrance to CR enrollment (delaying ease and efficiency of enrollment after procedures and hospitalizations) and patient burden (eg, added costs, logistic hassle, and anxiety). Nonetheless, exercise testing has enduring value for CR, especially because it reveals dynamic physiological responses as well as ischemia, arrhythmias, and symptoms pertinent to exercise prescription and training and to overall stability and prognosis. Moreover, as indications for CR have expanded, the value of exercise testing and functional assessment is more relevant than ever in the growing population of eligible patients, including those with heart failure, valvular heart disease, and posttransplantation, especially as current patients also tend to be more clinically complex, with advanced ages, multimorbidity, frailty, and obesity. This review focuses on the appropriate use of exercise testing in the CR setting. Graded exercise tests, cardiopulmonary exercise tests, submaximal walking tests, and other functional assessments (strength, frailty) for CR are discussed.

Can a Left Ventricular Assist Device in Individuals with Advanced Systolic Heart Failure Improve or Reverse Frailty

In the comic strip Peanuts , Charlie Brown allows his optimism and narrow focus to override his repeated objective experiences. He rushes at the football, only to have Lucy yank it away while he is in perfect midkick. Charlie launches into the air and falls, defeated again. This could be an

Mini-Focus Issue: Heart Failure With Preserved Ejection FractionEditorial CommentHospitalizations and Prognosis in Elderly Patients With Heart Failure and Preserved Ejection Fraction: Time to Treat the Whole Patient∗

Frailty, characterized by low physiological reserves, is strongly associated with vulnerability to adverse outcomes. Features of frailty overlap with those of advanced heart failure, making a distinction between them difficult. We sought to determine whether implantation of a left ventricular assist device (LVAD) would decrease frailty.