Chronic heart failure (HF) is a global epidemic. For the greater than 26 million world-wide patients with HF, this burden does not just cause an impairment in how blood is pumped out of the heart, HF impacts how all organ systems function and interact with one another. This means that HF constitutes a multi-organ syndrome as opposed to a disease of a single organ system, making it difficult to identify a “cure.” Unfortunately for patients, this means the impact of HF is felt daily and universally experienced as exercise intolerance and inability to comfortably perform activities of daily living. Fatigue and shortness of breath quickly overcome patients soon after engaging in even the most basic exercise such as walking to get the mail or climbing household stairs.
Since the seminal work of Weber and Janicki demonstrating that exercise intolerance does not simply impact the quality of life of HF patients, but is also strongly predictive of clinical severity, over 30 years have flown-by and we now know the “cure” for exercise intolerance is indeed the act of exercise itself. Despite this golden era of knowledge, there is a lot to be said about the pure translation of this rich information from “bench to bedside”.
An encouraging and globally impactful effort towards the ACSM Exercise is Medicine approach for the management of HF was recognized at center-stage following the 2009 publication of HF-ACTION. A large number of patients with HF and reduced ejection fraction (HFrEF; left ventricular ejection fraction of 35% or less) were shown to safely and clearly benefit from extended and structured aerobic and strength exercise training (ET) therapy (36 sessions; 3x/week; over 12 weeks). With the findings from HF-ACTION underpinning the support needed for the eventual 2014 policy recommending that Centers for Medicare & Medicaid Services (CMS) provide coverage for cardiac rehabilitation (CR) therapy for patients with HFrEF, it was believed that a “magic pill” for curing exercise intolerance and related signs and symptoms had been found. If only the “cure” was as simple as literally taking a pill.
Despite the exponential growth of studies, both domestic and international, since HF-ACTION supporting the medicinal role that ET therapy plays in managing signs and symptoms of HF, alarming underutilization of CR and ET continues to be reported (see here, here and here). Some important facts highlighted in recent reports focusing primarily on patients with HFrEF include:
- Less than 13% of CMS eligible patients are likely to receive referral for CR at discharge.
- Participation in at least one session of CR may be less than 3% out of all who are CMS eligible.
- Stable outpatients referred to CR (97%) as opposed to hospitalized inpatients (17%) referred to CR upon discharge are more likely to enroll.
What patients may not know is that CR is a Class I recommended therapy for HFrEF. This means CR is at the same status level as traditionally prescribed pharmacotherapies. Nevertheless, the data speaks for itself in illustrating the importance of the CR service-line has not been emphasized across the patient-to-clinician spectra to the point where it is appropriately being utilized.
Although the statistics are disappointing, the temptation for assigning responsibility for shortcomings must be resisted. Instead, it is important to look forward to the future and realize that all of us can still make significant changes to the running narrative of what CR means for HF patients. The well-intentioned hope of CMS coverage for CR should not be lost. There are ambitious campaigns focusing on improving education and awareness for both patients and clinicians highlighting the importance of CR, secondary prevention and life-long participation in exercise and physical activity.
Finally, conventional wisdom should lead all of us to the conclusion that ET therapy and HFrEF are not mutually exclusive events. Patients not classified as HFrEF, such as those diagnosed with HF and preserved ejection fraction (HFpEF; left ventricular ejection fraction of 50% or greater) or mid-range ejection fraction (HFmrEF; left ventricular ejection fraction of greater than 35% and less than 50%) are also logically to benefit from CR and ET therapy. There is no time sooner than now to force the narrative that all HF classes and etiologies stand to benefit from medically guided and individualized ET therapy.
Erik H. Van Iterson, Ph.D., is a member of the clinical staff and is the Director of Cardiac Rehabilitation in the Section of Preventive Cardiology & Rehabilitation in the Heart and Vascular Institute at the Cleveland Clinic, Cleveland OH.