Propensity-Matched Study of Early Cardiac Rehabilitation in Patients With Acute Decompensated Heart Failure

Abstract

Background: The impact of early implementation of cardiac rehabilitation (CR) in heart failure (HF) patients remains to be elucidated. This study sought to determine whether CR during HF hospitalization could improve prognostic outcomes in patients with acute decompensated HF.

Methods: We analyzed patients with HF enrolled in the JROADHF (Japanese Registry of Acute Decompensated Heart Failure) registry, a retrospective, multicenter, nationwide registry of patients hospitalized for acute decompensated HF. Eligible patients were divided into 2 groups according to CR during hospitalization. The primary outcome was a composite of cardiovascular death or rehospitalization due to cardiovascular event after discharge. The secondary outcomes were cardiovascular death and cardiovascular event rehospitalization.

Results: Out of 10 473 eligible patients, 3210 patients underwent CR. Propensity score matching yielded 2804 pairs. Mean age was 77±12 years and 3127 (55.8%) were male. During a mean follow-up of 2.8 years, the CR group had lower incidence rates of the composite outcome (291 versus 327 events per 1000 patient-years; rate ratio, 0.890 [95% CI, 0.830-0.954]; P=0.001) and rehospitalization due to cardiovascular event (262 versus 295 events per 1000 patient-years; rate ratio, 0.888 [95% CI, 0.825-0.956]; P=0.002) than the no CR group. In-hospital CR was associated with an improvement in Barthel index for activities of daily living (P=0.002). Patients with very low Barthel index at admission were benefited by CR in comparison with patients with independent Barthel index (very low; hazard ratio, 0.834 [95% CI, 0.742-0.938]: independent; hazard ratio, 0.985 [95% CI, 0.891-1.088]; P for interaction=0.035).

Conclusions: CR implementation during hospitalization was associated with better long-term outcomes in patients with acute decompensated HF. These data support the need for a randomized, controlled, adequately powered trial to definitively test the role of early physical rehabilitation in hospitalized patients with HF.

Keywords: cardiac rehabilitation; cardiovascular conditioning; heart failure; prognosis; quality of life.

Figure 1.

Patient selection. *Adjusted for age, sex, prior heart failure (HF) hospitalization, New York Heart Association functional class, etiology of HF, ischemic heart disease, hypertension, diabetes, stroke, chronic obstructive pulmonary disease, malignancy, heart rate, atrial fibrillation, pacemaker, implantable cardioverter defibrillator, cardiac resynchronization therapy-defibrillator, left ventricular ejection fraction, left ventricular mass index, hemoglobin, estimated glomerular filtration rate, angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker, mineralocorticoid receptor antagonist, beta-blockers, loop diuretics, thiazide, digitalis, oral inotropes, and amiodarone.

Figure 2.

Cumulative incidence curves for each outcome. Cumulative incidence curves for (A) cardiovascular (CV) death or CV event hospitalization, (B) CV death, and (C) CV event hospitalization in a propensity-matched cohort. HF indicates heart failure; and HR, hazard ratio.

Figure 3.

The effects of cardiac rehabilitation (CR) on changes of Barthel index from admission to discharge.

Figure 4.

Effects of cardiac rehabilitation (CR) on cardiovascular (CV) death or hospitalization according to Barthel index at admission.