Exercise and Heart Failure

1. Exercise and Heart Failure Tami Ward MS, APRN, NP-C, CHFN October 10, 2013

2. I have no conflict of interest

3. Discuss reduced ejection fraction(HFrEF) and preserved ejection fraction (HFpEF) heart failure • Examine the role and recommendations of exercise training in heart failure (HF) • Identify barriers and strategies to overcome these barriers in the HF population Objectives

4. The definition of HF has now expanded to:    a. HF with reduced ejection fraction • (HFrEF, EF≤40%)    b. HF failure with preserved ejection fraction (HFpEF EF ≥50%)    c. HFpEF, borderline (EF 41-49%)    d. HFpEF, improved (EF >40%) Two Types of HF

5. Definition of Heart Failure ACCF/AHA 2013 HF Guidelines JAC 2013 5 June (E-Pub online)

6. The number of patients with HF, as well as the cost to treat patients with HF, is expected to increase in the future. • All causes of HF must be evaluated, with consideration of multigenerational family histories and genetic testing. • Risk factors need to be continually addressed when managing a patient with HF: hypertension, lipid disorders, obesity, diabetes mellitus, tobacco use, and known cardiotoxic agents. • There is a clear mortality benefit from using guideline-directed medical therapy. Important points regarding HF management

7. Anticoagulation should not be used in patients with chronic HFrEF with no risk factors (atrial fibrillation, thromboembolic event, or cardioembolic source). • Aim for control of systolic and diastolic blood pressures, as well as volume status, to treat HFpEF. • Re-evaluate patients with left ventricular EF ≤35%, New York Heart Association class II-IV, left bundle branch block, and a QRS ≥150 ms for cardiac resynchronization therapy. • HF education, dietary restrictions, and exercise training should be provided for all patients to enhance self-care. • A HF multidisciplinary team, including a palliative care team, should be involved when treating patients with advanced HF. Important points regarding HF management

8. Classification of Heart Failure ACCF/AHA 2013 HF Guidelines JAC 2013 5 June (E-Pub online)

9. ACCF/AHA 2013 HF Guidelines JAC 2013 5 June (E-Pub online)

10. Exercise intolerance due to fatigue and dyspnea most prominent • Other S & S: • Paroxysmal nocturnal dyspnea • Orthopnea, • Edema • Worsening dyspnea with exertion or at rest • Tachycardia • Change in weight Signs and Symptoms in HF patients

15. Current Guidelines 2013: • Class I • Exercise training (or regular physical activity) is recommended as safe and effective for patients with HF who are able to participate to improve functional status (Level of Evidence: A) • Class IIa • Cardiac rehabilitation can be useful in clinically stable patients with HF to improve functional capacity, exercise duration, HRQOL, and mortality. (Level of Evidence: B) Role of Exercise Training in HF

16. Improvement in exercise capacity after exercise training due to peripheral adaptations (increased oxygen extraction) • Improvement in quality of life • Reduced hospitalizations and mortality • Improved endothelial function • Reduction in catecholamine levels Benefits with exercise and cardiac rehabilitation

17. Three major risk factors: age, presence of heart disease and intensity of exercise • Lowest incidence: walking, cycling and treadmill walking • Least active patients are higher risk • In HF patients, most common events include: post-exercise hypotension, atrial and ventricular arrhythmias and worsening HF symptoms Risks to exercise

18. Weight gain > 3 lb in 1-3 days • Drop in systolic BP with exercise (marked/symptomatic) • NYHA IV (can exercise selective patients) • Complex ventricular arrhythmias • Resting heart rate ≥ 100 bpm • Pre-existing unstable co-morbidities Relative Contraindications to Exercise in Stable HF Patients

19. Progressive worsening of exercise intolerance (dyspnea at rest) • Ischemia is suspected • Severe AS or severe regurgitant valvular disease • Acute systemic illness • New onset afib • Acute pericarditis/myocarditis/embolism Absolute Contraindications to Exercise with Stable HF Patients

20. Aerobic activity such as walking or cycling • Frequency – 3-5 days a week or most days • Intensity – 55-80% heart rate reserve with perceived exertion (11-14) • Duration of each session – start at 5 minutes if needed and progress to 30-60 minutes Exercise Recommendations

21. Cycling • Allows low level workloads • Easily reproducible • May be safer with orthopedic or balance problems • Walking • Swimming • yoga • Interval training • Flexibility and resistance training Exercise Recommendations

22. Patient related • Social and economic • Healthcare team/system • Condition and Therapy related Barriers and possible solutions

23. Older age • Low level of education • Low socio-economic status • Minority status • Anxiety and depression • Logistical problems • Lack of motivation, lack of insight into benefits and lack of time Patient related Barriers European Journal of Heart Failure (2012) 14, 451-458

24. Lack or resources and support • Lack of reimbursement • Transportation concerns Social and Economic Barriers European Journal of Heart Failure (2012) 14, 451-458

25. Lack of expertise with heart failure • Lack of capacity • Lack of referral • Lack of education on the importance of exercise Healthcare team/system barriers European Journal of Heart Failure (2012) 14, 451-458

26. Severity of symptoms • Level of disability • Rate of disease progression • Impact of co-morbidities Condition and Therapy Related Barriers European Journal of Heart Failure (2012) 14, 451-458

27. Patient related • Optimize heart failure management; manage co-morbid conditions • Discuss activity at each visit to rehab • Assess preferred mode of exercise • Education; engage patient as partner in exercise • Screen for depression Recommendations to overcome barriers

28. System and therapy related • Have referral system in place • Educate providers Recommendations to overcome barriers

29. 74 year-old male with history of coronary artery disease; inferior STEMI 2010 (unsuccessful PCI)complicated with cardiogenic shock and VT; initial EF 25%; received single chamber ICD • Hypertension • Hyperlipidemia • Osteoarthritis • Ischemic cardiomyopathy • insomnia Case study

30. Social History • Never used tobacco products • No alcohol and substance abuse • Retired lawyer • Family History • Father died of sudden death – age 60 • Surgical History • Cataracts; ICD implant Case Study

31. Medications • Aspirin 81mg daily • Carvedilol 12.5mg twice daily • Lisinopril 20mg daily (now on study drug – NEP inhibitor) • Furosemide 40mg twice daily • Potassium 20mEq daily • Simvastatin 40mg daily • Meloxicam as needed • Trazadone 25mg at bedtime • Nitroglycerine 0.4mg as needed Case study

32. Exercise history • Swimmer in high school • Lifeguard at the Officers Club Pool in the Army Medical Core • Cardiac rehab after STEMI • Resumed swimming after MI • U.S. Master’s • Senior Olympics Case Study

33. 9 Gold medals in Kansas Senior Meet - September ‘13

34. “My Doctor said if I hadn’t been in such good physical shape from swimming it very likely would have been a fatal heart attack. Swimming or any kind of exercise saves lives”.

35. Find strategies to get patients referred and enrolled in your cardiac rehabilitation program • Use this opportunity to give disease specific education to the HF patients • Prescribing exercise for HF patients is similar to patients without HF • Partner with your providers to help keep these patients out of the hospital with close surveillance of their symptoms. In Summary

36. Thank You! Tamra.Ward@Alegent.org