See Article by Warraich et al

Over 70% of Medicare beneficiaries who are hospitalized for heart failure (HF) die or are rehospitalized by 1 year after discharge.¹ Most suffer progressive functional decline, dependency, and poor quality of life over time. Although such grim outcomes are commonly attributed to cardiac disease, noncardiovascular complexities are also detrimental.² Older adults hospitalized for HF are particularly vulnerable to the adverse effects from muscle atrophy,³ disability, confusion, comorbidities, and other intricacies which undermine potential for recovery and survival. Whereas physical activity is recommended as part of the guidelines for recovery in patients hospitalized for HF,⁴ the majority of older HF patients remain sedentary, often challenged by their noncardiovascular conditions. REHAB-HF (Rehabilitation Therapy in Older Acute Heart Failure Patients) is a ground-breaking HF exercise trial⁵ that is designed to fill the gaps left by the HF-ACTION trial (Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training).⁶ The primary focus of the REHAB-HF trial is the utility of exercise therapy after acute hospitalization among older adults. In their report of a subset of REHAB-HF enrollees, Warraich et al⁷ extend the value of REHAB-HF by delineating important characteristics of this population that constitute critical impediments to exercise interventions.

HF-ACTION is widely promulgated as an endorsement of exercise therapy for HF, yet it is commonly criticized for inherent limitations.⁸ End points included reduced all-cause mortality and hospitalization and improved quality of life with aerobic exercise in a diverse population already receiving optimal medical therapy.^6,9,10 Still, statistically significant benefits of the exercise intervention for mortality and rehospitalization were only detected after adjustment for baseline characteristics predictive of these clinical outcomes (cardiopulmonary exercise test duration, left ventricular ejection fraction, depression, atrial fibrillation).⁸ Such statistical tweaking is regarded by many as a limitation, but more fundamentally, HF-ACTION enrolled only patients with EF ≤35% and excluded patients hospitalized in the past 6 weeks. Such restrictions overlook the potential utility of exercise in the many HF patients with preserved EF (which is particularly prevalent in older adults), and during the critical posthospitalization period when functional decline and rehospitalization are most likely to occur.¹¹ An even more prominent criticism of HF-ACTION was the remarkably poor adherence it achieved with its exercise intervention despite considerable prompting and support. Patients attended on average only 1.8 of the prescribed 3 sessions/week. With the benefit of hindsight, it is notable that HF-ACTION failed to consider common noncardiovascular impediments to adherence such as multimorbidity, frailty, and cognitive impairment. Furthermore, the absence of strength, balance, or mobility training in HF-ACTION may have further exacerbated poor adherence, by omitting critical aspects of conditioning that address the idiosyncratic needs in this population (ie, they were too weak for the purely aerobic HF-ACTION intervention); this ultimately may have reduced the potential to successfully execute the protocol.

The REHAB-HF trial is addressing these shortcomings with a physical therapy, site-based intervention designed to improve the strength, balance, endurance, and mobility of older adults hospitalized for HF, regardless of ejection fraction.⁵ The REHAB-HF trial is enrolling patients ≥60 years old who are hospitalized for HF and are expected to be discharged home. The intervention begins during hospitalization and continues after discharge 3 days per week for 12 weeks. The baseline characteristics of the first 202 (out of 360) patients enrolled in the REHAB-HF trial are reported in this issue of Circulation: Heart Failure. The report highlights the large number of comorbid illnesses and high prevalence of depression, cognitive impairment, debilitating HF symptoms, and physical frailty. Although the REHAB-HF intervention focuses primarily on exercise therapy to improve physical deficits, this report expands the value of the trial by recognizing the diverse dimensions that impact exercise feasibility and sustainability.¹² Such perspectives can not only be used to shape exercise prescription, but to ultimately inform exercise and wellness strategies that can be further studied as part of multifaceted cardiac rehabilitation programs.

Comorbid conditions are associated with reduced exercise adherence among patients with HF.¹² REHAB-HF participants have an average of ≥5 comorbid illnesses. Comorbid illnesses that limit mobility—such as arthritis or neurological conditions—may prevent patients from participating in exercise or rehabilitation. Furthermore, comorbid illnesses compete for patients’ time, attention, financial, and social resources. For example, patients with diabetes mellitus must check their blood sugar, adhere to a low carbohydrate diet, go to appointments for diabetes mellitus control, and (in some cases) take medications to control blood sugar. All of these activities may cause patients to place less absolute importance on HF and, therefore, detract from participation in an exercise training program.

Depression is a key comorbid illness in HF. Depression is associated with reduced adherence to exercise training,¹² although exercise is one of the few successful interventions among patients with depression and HF.^2,13 In REHAB-HF, depression is particularly prominent in patients with HF with preserved ejection fraction and is clinically under-recognized (ie, depression was not mentioned in the patient’s chart, but the patient screened positive on the Geriatric Depression Scale, which was administered as part of the study). Depression may be clinically under-recognized in HF because it is difficult to treat. Antidepressants are often less effective for depression in HF patients, and cognitive behavioral therapy, one of the few efficacious interventions in this population,¹⁴ is not routinely available in most cardiology clinics. These challenges may lead to untreated depression reducing adherence in the REHAB-HF intervention arm.

Cognitive impairment was present in a remarkable 78% of REHAB-HF participants. Cognitive impairment represents a challenge to HF self-care²; however, mild cognitive impairment (ie, objective memory loss but able to function in day-to-day life) in and of itself is not a barrier to exercise. Some data suggest that exercise improves cognitive performance.¹⁵ However, patients with cognitive impairment will require greater caregiver support for transportation and remembering to perform home exercises.

HF-specific health status, as measured by the Kansas City Cardiomyopathy Questionnaire, is very poor among REHAB-HF participants. Poor Kansas City Cardiomyopathy Questionnaire scores reflect the highly symptomatic nature of these patients. Unfortunately, bothersome HF symptoms are associated with reduced adherence to exercise training.¹² Therefore, ensuring excellent medical management of HF to minimize these symptoms may be important to exercise adherence.

Physical frailty, as measured by the Fried criteria,¹⁶ was also highly prevalent among REHAB-HF participants (53%). Physical frailty is considered present if ≥3 Fried criteria are met: unintentional weight loss, exhaustion, slow gait speed, weak handgrip strength, or low physical activity.¹⁶ The effect of physical frailty on exercise adherence is not known in the HF population; however, the slow gait speed, weak handgrip strength, and low physical activity components of the Fried criteria would likely respond to exercise and to the REHAB-HF intervention in particular. The exhaustion and unintentional weight loss components of the Fried criteria may hinder exercise adherence. Final results of the REHAB-HF trial may shed more light on the interaction between physical frailty and adherence to exercise training.

The REHAB-HF investigators are commended for designing an exercise intervention spanning the intersecting fields of geriatric cardiology, HF hospitalization, and exercise science. The high burden of comorbid illness and high prevalence of depression, cognitive impairment, debilitating HF symptoms, and physical frailty have wide-reaching implications, both for exercise therapy but also for geriatric HF care in general. Although we wait for the REHAB-HF trial to finish enrollment and follow-up, it seems prudent for clinicians caring for older adults with HF to promote physical activity and to consider strategies to overcome common noncardiovascular impediments in this vulnerable patient population.

Whereas REHAB-HF is a clinical trial designed to specifically study the benefits of exercise training as a rigorous therapeutic intervention, multifaceted cardiac rehabilitation programs tailored to this population are still needed. Cardiac rehabilitation has complementary potential to emphasize critical aspects of adherence that are especially challenging amid geriatric impediments. A recent position paper defined 4 domains of geriatric HF care; physical function was only 1 of them.² For patients to succeed in a rigorous exercise rehabilitation program like REHAB-HF, clinicians will need to address barriers in the other 3 domains (Medical, Mind and Emotion, and Social Environment). For example, careful, patient-centered deprescribing may decrease bothersome symptoms from polypharmacy that may deplete energy, blunt cognition, and exacerbate other impediments to daily activity. Alerting caregivers to a patient’s cognitive impairment, and thus need for greater supervision of day-to-day self-care activities, may help patients remain out of the hospital and provide them with the extra support needed to participate regularly in an exercise or rehabilitation program. Identification of financial or transportation problems may prompt clinicians to harness community resources to help patients and potentially suggest home- over site-based programs.

The baseline characteristics of the first 202 REHAB-HF participants describe a vulnerable population with multiple comorbid illnesses and highly prevalent depression, cognitive impairment, bothersome HF symptoms, and physical frailty. These initial data not only describe the challenges faced by the REHAB-HF investigators in ensuring adherence to the REHAB-HF intervention, but they also represent a call to action for HF clinicians and investigators alike. Although we await the final trial results of REHAB-HF, we should focus on leveraging the detailed characterization of the REHAB-HF participants to improve the clinical care of, and development of novel interventions for, older adults hospitalized for HF.

None.

The opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.

参见Warraich等的文章

因心力衰竭（HF）住院的Medicare受益人中有70％以上在出院后1年死亡或重新住院。¹大多数人会随着时间的推移逐渐遭受功能衰退，依赖和生活质量下降。尽管这种严峻的结果通常归因于心脏病，但非心血管的复杂性也是有害的。^2对住院HF老年人特别容易从肌肉萎缩，不利影响³残疾，混乱，合并症，和其它的复杂因素破坏的恢复和存活的潜力。尽管建议进行体育锻炼是住院心衰患者康复指南的一部分，⁴大多数老年HF患者久坐不动，经常受到非心血管疾病的困扰。REHAB-HF（老年急性心力衰竭患者的康复治疗）是一项开创性的HF运动试验⁵，旨在弥补HF-ACTION试验（心力衰竭：运动训练的对照试验结果）所留下的空白。⁶ REHAB-HF试验的主要重点是老年人急性住院后运动疗法的实用性。Warraich等[ ^7]在报告REHAB-HF参与者的子集时，通过描述该人群的重要特征（构成锻炼干预的主要障碍），扩展了REHAB-HF的价值。

HF-ACTION被广泛地发布为对HF的运动疗法的认可，但通常因其固有的局限性而受到批评。⁸终点包括在已经接受最佳药物治疗的不同人群中，通过有氧运动降低全因死亡率和住院率，并改善生活质量。^[6,9,10]不过，只有在调整了预测这些临床结果（心肺运动测试持续时间，左心室射血分数，抑郁症，心房颤动）的基线特征后，才能发现运动干预对死亡率和再次住院的统计学意义显着。⁸许多人认为这种统计调整是一个限制，但从根本上来说，HF-ACTION仅招募了EF≤35％的患者，而排除了过去6周内住院的患者。这样的限制忽略了在许多保留了EF的HF患者中进行运动的潜在效​​用（在老年人中尤为普遍），以及在关键的入院后关键时期，最有可能发生功能下降和再入院。¹¹对HF-ACTION的一个更为突出的批评是，尽管有相当多的提示和支持，但通过运动干预却无法达到很强的依从性。病人平均每周仅参加规定的3个疗程中的1.8个。借助事后观察，值得注意的是，HF-ACTION未能考虑到依从性的常见非心血管障碍，例如多发病，虚弱和认知障碍。此外，在HF-ACTION中缺乏力量，平衡或活动能力训练，可能会进一步消除依从性的关键问题，因为它忽略了满足该人群特质需求的调理的关键方面（即，对于纯有氧HF-S来说太弱了） ACTION干预）；这最终可能降低了成功执行协议的可能性。

REHAB-HF试验通过物理疗法，基于部位的干预措施来解决这些缺点，旨在提高住院治疗HF的老年人的强度，平衡，耐力和活动能力，而与射血分数无关。⁵ REHAB-HF试验招募了≥60岁的因HF住院且有望出院的患者。干预开始于住院期间，并于每周出院3天后持续12周。在本期《循环：心力衰竭》中报道了参加REHAB-HF试验的前202名（360名）患者的基线特征。该报告强调了大量合并症，以及抑郁症，认知障碍，心衰乏力症状和身体虚弱的高患病率。尽管REHAB-HF干预主要集中于运动疗法以改善身体缺陷，但该报告通过认识到影响运动可行性和可持续性的各个方面，扩大了试验的价值。¹²这些观点不仅可以用来制定运动处方，还可以最终为运动和健康策略提供依据，这些策略可以作为多方面心脏康复计划的一部分进行进一步研究。

合并症与HF患者的运动依从性降低有关。^12名REHAB-HF参与者平均患有5种以上的合并症。限制活动能力的合并症（例如关节炎或神经系统疾病）可能会阻止患者参加运动或康复。此外，合并症会争夺患者的时间，注意力，财力和社会资源。例如，患有糖尿病的患者必须检查血糖，坚持低碳水化合物饮食，预约糖尿病控制，以及（在某些情况下）服用药物来控制血糖。所有这些活动可能会使患者对HF的重视度降低，因此有损于参加运动训练计划。

抑郁症是心衰的一种主要的合并症。抑郁症与减少对运动训练的依从性有关，[ ^12]尽管运动是抑郁症和心衰患者中为数不多的成功干预措施之一。^2,13在REHAB-HF中，抑郁症在射血分数保持不变的HF患者中尤为突出，临床上并未得到充分认识（即，患者图表中未提及抑郁症，但患者在老年抑郁量表上筛查为阳性。是研究的一部分）。在抑郁症中，由于难以治疗，因此在临床上对抑郁症的认识不足。抗抑郁药通常对HF患者的抑郁症无效，而认知行为疗法是该人群中为数不多的有效干预措施之一，大多数心脏病诊所通常没有提供^14的医疗服务。这些挑战可能导致未经治疗的抑郁症，从而降低REHAB-HF干预组的依从性。

78％的REHAB-HF参与者存在认知障碍。认知障碍代表了对HF自我护理的挑战²；然而，轻度的认知障碍（即客观记忆丧失但能够在日常生活中发挥作用）本身并不构成锻炼的障碍。一些数据表明，锻炼可以改善认知能力。¹⁵然而，患有认知障碍的患者将需要更多的照顾者支持以运输和记住进行家庭锻炼。

根据堪萨斯城心肌病问卷调查，HF特定的健康状况在REHAB-HF参与者中非常差。堪萨斯城心肌病问卷的评分不佳反映了这些患者的高度症状性。不幸的是，烦躁的HF症状与对运动训练的依从性降低有关。¹²因此，确保对HF进行良好的医疗管理以最大程度地减少这些症状，可能对锻炼依从性很重要。

根据弗里德标准衡量，身体虚弱¹⁶在REHAB-HF参与者中也很普遍（53％）。如果满足≥3 Fried标准，则认为存在身体虚弱：无意识的体重减轻，疲惫，步态速度慢，手握力弱或体育活动低。¹⁶在HF人群中，身体虚弱对运动依从性的影响尚不清楚。但是，Fried标准的慢步态速度，较弱的握力和较低的身体活动成分可能会对运动尤其是对REHAB-HF干预产生反应。Fried标准的疲劳和无意识减肥成分可能会阻碍运动坚持。REHAB-HF试验的最终结果可能会更好地说明身体虚弱与坚持运动训练之间的相互作用。

REHAB-HF研究人员在设计运动干预措施时受到赞扬，该运动干预措施涉及老年心脏病学，HF住院治疗和运动科学的交叉领域。合并症的高负担和抑郁症，认知障碍，心衰乏力的症状以及身体虚弱的高患病率对运动疗法和一般的老年心衰患者都有广泛的影响。尽管我们等待REHAB-HF试验完成入组和随访，但对于临床医生而言，照顾老年人患有HF可以促进体力活动并考虑克服这一弱势患者群体中常见的非心血管障碍的策略似乎是审慎的做法。

尽管REHAB-HF是一项旨在专门研究运动训练作为严格治疗干预措施的益处的临床试验，但仍需要针对该人群的多方面心脏康复计划。心脏康复具有互补的潜力，可以强调依从性的关键方面，这些方面在老年医学障碍中尤其具有挑战性。最近的立场文件定义了老年性HF护理的4个领域。身体机能只有其中之一。^2个为了使患者成功通过严格的运动康复计划（如REHAB-HF），临床医生将需要解决其他3个领域（医疗，心理和情感以及社会环境）中的障碍。例如，以患者为中心的谨慎用药可能会减轻多药店带来的烦人症状，这些症状可能会消耗能量，钝化认知并加剧其他日常活动障碍。提醒护理人员患者的认知障碍，因此需要加强对日常自我护理活动的监督，可以帮助患者远离医院，并为他们提供定期参加运动或康复计划所需的额外支持。

前202名REHAB-HF参与者的基线特征描述了一个易感人群，患有多种合并症，高度流行的抑郁症，认知障碍，HF症状困扰和身体虚弱。这些初始数据不仅描述了REHAB-HF研究者在确保遵守REHAB-HF干预措施方面面临的挑战，而且还代表了HF临床医生和研究者都应采取行动。尽管我们正在等待REHAB-HF的最终试验结果，但我们应该集中精力利用REHAB-HF参与者的详细特征，以改善对因HF住院的老年人的临床护理并开发新的干预措施。

没有任何。

本文表达的观点不一定是编辑者或美国心脏协会的观点。