Cardiac rehabilitation for heart failure: ‘Cinderella’ or evidence-based pillar of care?

Abstract

Cardiac rehabilitation remains the ‘Cinderella’ of treatments for heart failure. This state-of-the-art review provides a contemporary update on the evidence base, clinical guidance, and status of cardiac rehabilitation delivery for patients with heart failure. Given that cardiac rehabilitation participation results in important improvements in patient outcomes, including health-related quality of life, this review argues that an exercise-based rehabilitation is a key pillar of heart failure management alongside drug and medical device provision. To drive future improvements in access and uptake, health services should offer heart failure patients a choice of evidence-based modes of rehabilitation delivery, including home, supported by digital technology, alongside traditional centre-based programmes (or combinations of modes, ‘hybrid’) and according to stage of disease and patient preference.

Lifestyle Walking Intervention for Patients With Heart Failure With Reduced Ejection Fraction: The WATCHFUL Trial

“…9,10 In addition, the demanding intensity of the exercises, logistical issues such as transportation difficulties and inconvenient scheduling, and individual time constraints contribute to lower adherence rates. 11,12 In addition, these programs often fail to induce sustained behavioral change, resulting in their effect being frequently short-term. 13 Lifestyle PA interventions have emerged as an alternative approach.…”

Exercise‐based cardiac rehabilitation for adults with heart failure – 2023 Cochrane systematic review and meta‐analysis

“…Increasing recognition, not only of the need to reduce the risk of clinical events and improve survival of HF patients, but also to optimize HRQoL, underscores the importance of rehabilitation 54,55 . As proposed by a recent state of the art review, evidence for ExCR, supports its place as a ‘fifth pillar’ of HF management and alongside the four classes of drugs, that is, angiotensin receptor–neprilysin inhibitors, beta‐blockers, mineralocorticoid receptor antagonists, and sodium–glucose cotransporter 2 inhibitors 9 . Whilst this review found the patient characteristics to be broadly similar across trials, irrespective of the mode of delivery, given their less intensive supervision, patients should be carefully selected for home‐based (and digitally supported) programmes.…”

“…54,55 As proposed by a recent state of the art review, evidence for ExCR, supports its place as a 'fifth pillar' of HF management and alongside the four classes of drugs, that is, angiotensin receptor-neprilysin inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 inhibitors. 9 Whilst this review found the patient characteristics to be broadly similar across trials, irrespective of the mode of delivery, given their less intensive supervision, patients should be carefully selected for home-based (and digitally supported) programmes. The scientific statement from the American Association of Cardiovascular and Pulmonary Rehabilitation, the American Heart Association, and the American College of Cardiology recommend the use of home-based models, should be limited to patients who are clinically stable, at low to moderate risk, and who cannot attend a traditional supervised centre-based programme.…”

“…[6][7][8] Whilst the reasons for poor access are complex and include system-, clinician-, and patient-level barriers, a key factor is setting of ExCR delivery. 9 Traditionally delivered in a supervised centre-based setting, access to ExCR has been further challenged during and following the COVID-19 pandemic. 10 As a result, there have been calls for healthcare systems to move to alternative ExCR delivery models that include home-based programmes that can be digitally supported, and hybrid programmes combining elements of both centre and home participation.…”

“…Despite robust evidence and strong recommendation, the uptake remains low with less than 20% of patients with HF across United States and Europe receiving exercise‐based cardiac rehabilitation (ExCR) 6–8 . Whilst the reasons for poor access are complex and include system‐, clinician‐, and patient‐level barriers, a key factor is setting of ExCR delivery 9 . Traditionally delivered in a supervised centre‐based setting, access to ExCR has been further challenged during and following the COVID‐19 pandemic 10 .…”