Jenny Wingham

Home-based cardiac rehabilitation for people with heart failure: A systematic review and meta-analysis

AIMS To assess the effectiveness of home-based cardiac rehabilitation (CR) for heart failure compared to either usual medical care (i.e. no CR) or centre-based CR on mortality, morbidity, exercise capacity, health-related quality of life, drop out, adherence rates, and costs. METHODS Randomised controlled trials were initially identified from previous systematic reviews of CR. We undertook updated literature searches of MEDLINE, EMBASE, CINAHL, PsycINFO and Cochrane Library to December 2015. A total of 19 trials with median follow up of 3months were included - 17 comparisons of home-based CR to usual care (995 patients) and four comparing home and centre-based CR (295 patients). RESULTS Compared to usual care, home-based CR improved VO2max (mean difference: 1.6ml/kg/min, 0.8 to 2.4) and total Minnesota Living with Quality of Life score (-3.3, -7.5 to 1.0), with no difference in mortality, hospitalisation or study drop out. Outcomes and costs were similar between home-based and centre-based CR with the exception of higher levels of trial completion in the home-based group (relative risk: 1.2, 1.0 to 1.3). CONCLUSIONS Home-based CR results in short-term improvements in exercise capacity and health-related quality of life of heart failure patients compared to usual care. The magnitude of outcome improvement is similar to centre-based CR. Home-based CR appears to be safe with no evidence of increased risk of hospitalisation or death. These findings support the provision of home-based CR for heart failure as an evidence-based alternative to the traditional centre-based model of provision.

Participant and caregiver experience of the Nintendo Wii SportsTM after stroke: qualitative study of the trial of WiiTM in stroke (TWIST)

Objective: To understand stroke survivors and their caregivers’ experience and acceptability of using the Nintendo Wii SportsTM games (WiiTM) as a home-based arm rehabilitation tool. Design: A qualitative study within a randomized controlled trial investigating the effectiveness of using the WiiTM for arm rehabilitation. Data were analysed using thematic analysis. Settings: Participants and carers were interviewed in their homes. Subjects: Eleven male and seven female participants and 10 caregivers who were taking part in the randomized controlled trial within six months of stroke. Median age 65. Intervention: All participants were using the WiiTM for arm rehabilitation. Main Measures: Semi-structured interviews. Results: Five themes were identified: diligence of play, perceived effectiveness, acceptability, caregiver and social support, and the set-up and administration of the WiiTM. Participants appreciated the ability to maintain a social role and manage other comorbidities around the use of the WiiTM. A small number of participants found the Mii characters too childlike for adult rehabilitation. The most popular game to start the rehabilitation programme was bowling. As confidence grew, tennis was the most popular, with baseball and boxing being the least popular games. Caregivers provided some practical support and encouragement to play the WiiTM. Conclusions: The WiiTM may provide an engaging and flexible form of rehabilitation with relatively high reported usage rates in a home setting. The WiiTM was acceptable to this sample of patients and their caregivers in home-based rehabilitation of the arm following stroke.

Involving primary care and cardiac rehabilitation in a reorganised service could improve outcomes

To the Editor The full National Heart Failure Audit report1 and a recent editorial in the Lancet endorse the reports conclusion that it ‘provides a powerful incentive to reorganise heart failure care in the UK’.1 2 The suggested solution is to provide specialist care similar to that given to people after heart attacks citing that such specialised units ‘could do for heart failure …

Home based cardiac rehabilitation could improve outcomes

Denvir and Zamvar cite practical problems in attending cardiac rehabilitation after cardiac surgery as a barrier for uptake in poorer patients.1 Two recent randomised controlled trials …

Rehabilitation Enablement in Chronic Heart Failure—a facilitated self-care rehabilitation intervention in patients with heart failure with preserved ejection fraction (REACH-HFpEF) and their caregivers: rationale and protocol for a single-centre pilot randomised controlled trial

Introduction The Rehabilitation EnAblement in CHronic Heart Failure in patients with Heart Failure (HF) with preserved ejection fraction (REACH-HFpEF) pilot trial is part of a research programme designed to develop and evaluate a facilitated, home-based, self-help rehabilitation intervention to improve self-care and quality of life (QoL) in heart failure patients and their caregivers. We will assess the feasibility of a definitive trial of the REACH-HF intervention in patients with HFpEF and their caregivers. The impact of the REACH-HF intervention on echocardiographic outcomes and bloodborne biomarkers will also be assessed. Methods and analysis A single-centre parallel two-group randomised controlled trial (RCT) with 1:1 individual allocation to the REACH-HF intervention plus usual care (intervention) or usual care alone (control) in 50 HFpEF patients and their caregivers. The REACH-HF intervention comprises a REACH-HF manual with supplementary tools, delivered by trained facilitators over 12 weeks. A mixed methods approach will be used to assess estimation of recruitment and retention rates; fidelity of REACH-HF manual delivery; identification of barriers to participation and adherence to the intervention and study protocol; feasibility of data collection and outcome burden. We will assess the variance in study outcomes to inform a definitive study sample size and assess methods for the collection of resource use and intervention delivery cost data to develop the cost-effectiveness analyses framework for any future trial. Patient outcomes collected at baseline, 4 and 6 months include QoL, psychological well-being, exercise capacity, physical activity and HF-related hospitalisation. Caregiver outcomes will also be assessed, and a substudy will evaluate impact of the REACH-HF manual on resting global cardiovascular function and bloodborne biomarkers in HFpEF patients. Ethics and dissemination The study is approved by the East of Scotland Research Ethics Service (Ref: 15/ES/0036). Findings will be disseminated via journals and presentations to clinicians, commissioners and service users. Trial registration number ISRCTN78539530; Pre-results .

Acute coronary syndromes: key role of rehabilitation and primary care in long term secondary prevention

Timmis’s review on the management of acute coronary syndrome is timely and comprehensive but fails to mention the role of primary care in the aftercare of patients discharged from hospital.1 The review acknowledges that with recent advances patients admitted with acute myocardial infarction are discharged home after 48-72 hours and secondary prevention aimed at reducing the risk of recurrent acute coronary syndrome should …

47 Rehabilitation enablement in chronic heart failure (reach-HF) a multicentre randomised controlled trial of facilitated self-care rehabilitation intervention in heart failure with reduced ejection fraction

Introduction Evidence from systematic reviews and meta-analyses of randomised trials has led the National Institute of health and Care Excellence (NICE) and international guideline bodies to recommend centre-based cardiac rehabilitation (CR) as an effective and safe intervention for heart failure. CR reduces the risk of hospitalisations and improves health related quality of life (HRQoL). Nevertheless, CR uptake for heart failure (HF) remains suboptimal and alternative delivery models, such as home-based programmes are therefore needed. The REACH-HF multi-centre trial (ISRCTN86234930) was designed to evaluate the effectiveness of a novel evidence-informed home-based rehabilitation intervention in heart failure with reduced ejection fraction (HFrEF) patients. Methods Patients from 4 UK centres with a left ventricular ejection fraction of <45% were randomised 1:1 between January 2015 and February 2016 to the REACH-HF intervention (self-help manual facilitated by trained nurses or physiotherapists over 12 weeks) plus usual care (intervention group) or usual care alone (control group). Outcome data was collected at baseline at 4, 6 and 12 months. The primary outcome was the disease specific HRQoL using the Minnesota Living with Heart Failure questionnaire (MLHFQ) at 12 months. Secondary outcomes included death, hospitalisation, generic quality of life (EuroQol-5-Dimension-EQ-5D-5L), psychological well-being (Hospital Anxiety and Depression Scale, HADS), exercise capacity (incremental shuttle walk test-ISWT), and physical activity (accelerometry). Results We met our recruitment target of 216 patients (mean age 69.8 years, 78.5% male; 80% with New York Heart Association (NYHA) Class II/III). Compared with control, the intervention group was associated with a clinically meaningful improvement in the total MLHFQ score at 12 month follow up of −5.7 (95% CI: −10.6 to −0.7, p=0.025, intention to treat analysis). At 12 months there were a total of 8 deaths – 4 in each group and 19 hospital admissions in the intervention group and 24 in controls – 3 versus 6 HF-related admissions respectively. There was no between group difference in mean EQ-5D-5L (−0.024,–0.091 to 0.04), 0.49), HADS Anxiety score (0.1 (-0.8 to 1.0), 0.83), HADS Depression score (−0.2 (-1.1 to 0.6), 0.56) or in exercise capacity (ISWT in metres: 0.1 (-33.3 to 33.5), 1.0) and physical activity (number of days per week with at least 10 min per day activity >100 millig-unit: 0.2 (-0.4 to 0.7), 0.6). Conclusion Our findings indicate that the addition of the REACH-HF home-based rehabilitation-intervention to usual care for the management of HFrEF results in clinically important improvements in disease-specific HRQoL and has the potential to reduce hospital admissions. The REACH-HF intervention had no impact on generic HRQoL, psychological well-being, exercise capacity or physical activity.

Nurse led clinics can improve secondary prevention after coronary events

Minerva notes that the majority of patients with coronary heart disease in a recent Norwegian survey failed to achieve the targets for secondary prevention.1 The study indicates that the intervention was led and monitored in secondary care with no input from general practitioners. …