EXERCISE PRESCRIPTION FOR CHF

1. Chuck Kitchen, MA, FAACVPR Chuck.kitchen@gmail.com EXERCISE PRESCRIPTION FOR CHF

2. CELEBRATION

3. POSTED 2-18-14 • http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=270

4. NATIONAL COVERAGE DETERMINATION NCD 20:10 • Effective date: February 18, 2014 • CAG # 00437N  • HF patients are not eligible for ICR • Evidence of benefit based on CR model, not ICR

5. MEDICARE PROVISION FOR CR Same regulation for HF: 42 CFR 410.49 • 1-2 hour sessions/day • > 91 minutes=2 sessions • < 90 minutes=1 session • Up to 36 sessions per course • Up to 36 weeks to complete CR course • Required components • Physician-prescribed exercise (CR team) • Cardiac risk factor reduction interventions

6. ELIGIBILITY CRITERIA • CMS criteria were derived from HF-ACTION Trial for patient eligibility. • Research design often differs from “real world” procedure for valid reasons.

7. ELIGIBILITY CRITERIA Beneficiaries with stable, chronic heart failure meeting ALL of following: • Left ventricular ejection fraction < 35% • NYHA class II-IV symptoms despite being on optimal heart failure therapy for at least 6 weeks • Stable=have not had recent (< 6 weeks) or planned (< 6 months) major cardiovascular hospitalizations or procedures

8. ELIGIBILITY CRITERIA Beneficiaries with stable, chronic heart failure meeting all of following: • Left ventricular ejection fraction < 35% • Measurement by any method is OK • EF >35% not eligible • EF not always an exact measurement

9. ELIGIBILITY CRITERIA Beneficiaries with stable, chronic heart failure meeting all of following: • NYHA class II-IV symptoms despite being on optimal heart failure therapy for at least 6 weeks • Goal for HF patients is not symptom-free, but that patients are able to monitor and control their symptoms • Similar to stable angina

10. NYHA CLASSIFICATION

11. ELIGIBILITY CRITERIA Beneficiaries with stable, chronic heart failure meeting all of following: • Stable=have not had recent (< 6 weeks) or planned (< 6 months) major cardiovascular hospitalizations or procedures • Hospitalization is not required • No per year or per lifetime limit, as with all CR dx

12. ELIGIBILITY CONSIDERATIONS • 30-day all-cause re-admission penalties for HF dx • Role for CR to provide transitional treatment to improve care coordination • Start education earlier post-DC?

13. ELIGIBILITY CONSIDERATIONS • What about patient with AMI who has EF < 35%? • What about patient who would benefit from > 36 sessions? • Similarities to stable angina diagnosis • Goal is to prepare patient for self-management

14. PREVELENCE OF HEART FAILURE

15. HOSPITAL DISCHARGE CHF

16. COST OF CHF

17. HEART FAILURE • 5.1 MILLION people have CHF • 825,000 new cases per year • 279,000 total mention mortality-2010 • 57,000 underlying cause 2010 • 1,084,000 hospital discharges-2005 • Estimated cost 2005-34.8 BILLION

18. IS EXERCISE SAFE FOR CHF • YES!!! • HF-ACTION TRIAL

19. HF ACTION STUDY • There was a small reduction in the combined end-point of all cause death or all-cause hospitalization. This was the primary endpoint for the trial and is what is driving some of the media headlines. • There was a modest reduction in the important protocol-specified disease-specific combined end-point of CV death or HF hospitalization. Yes, this ~14% reduction is modest, but please note that this improvement occurred in patients already receiving (on-top-of) excellent evidence-based background therapy…. ~92% were on ACE inhibitors or angiotensin receptor blockers; 95% on beta-blockade; and 40% were enrolled with ICD device already implanted.

20. HF ACTION STUDY • Exercise did not increase the risk for events. • There was a modest improvement in quality of life scores among the patients in the exercise group. • Finally, “Based on the safety of exercise training and the modest reduction in clinical events, the HF-ACTION study results support a prescribed exercise training program for patients with reduced LV function and HF symptoms in addition to evidence-based therapy.” Steven Keteyian, PhD CEPA website

21. CLINICAL CONSIDERATIONS FOR HF & CR “Cardiac Rehabilitation Exercise and Self-Care for Chronic Heart Failure”. Ades PA, Keteyian SJ, Balady GJ, Houston-Miller N, et al. JACC Heart Fail 2013;1:540-547. • Evidence to support • Exercise prescription • Self-care counseling

22. EXERCISE PRESCRIPTION • Constant Work Rate (CWR) • The workload is fixed and remains the same throughout the exercise session • Example: Treadmill 3.0mph 2% grade for 20 min • Interval Training • The workload varies throughout the exercise session. • Example: Treadmill 2.5mph 2% grade for 5 min increase to 3.0mph 3.5% grade for 5 min, etc

23. EXERCISE PRESCRIPTION • AIT-Aerobic Interval Training • MCT-Moderate Continuous Training • MICE-Moderate Intensity Aerobic Continuous Exercise • HIIE-High Intensity Aerobic Interval Exercise

24. EXERCISE PRESCRIPTION • Exercise Intensity Domains • Assumes the use of CWR method • Light to Moderate • Moderate to High • High to Severe • Severe to Extreme

25. LIGHT TO MODERATE INTENSITY • All work rates with steady state VO2 below the 1st VT. • Blood lactate does not elevate above resting levels • Metabolism is aerobic • Generally well tolerated with modest fatigue • Able to maintain for greater than 30-40 minutes

26. MODERATE TO HIGH INTENSITY • Work rates between 1st VT and CP • Typically can be sustained for about 30 min

27. HIGH TO SEVERE INTENSITY • All work rates above CP • No steady state is achieved • Blood lactate continually rises • Duration less than 20 minutes • Can only be used for interval training, not continuous

28. SEVERE TO EXTREME INTENSITY • Work rate is so high that fatigue comes before peak VO2 can be reached • Less than 3 minutes duration • As a result of short duration blood lactate levels not as high as with High to Severe intensity

29. EXERCISE PRESCRIPTION

30. EXERCISE PRESCRIPTION

31. INTERVAL PRESCRIPTION Intervals-Green Arrows 85-95% 4 minutes Cool-down 60-70% 3-5 minutes Warm-up 60-70% 8-10 minutes Active Recovery-Blue 60-70% 3 minutes

32. AIT VS MCT * * AIT MCT

33. VARIOIUS EXERCISE INTENSITIES • Meta analysis, over 5800 patients • High intensity, vigorous intensity, moderate intensity, low intensity groups • Peak VO2 increased 23% in High intensity vs control • Vigorous and moderate intensity also showed significant improvement • Low intensity did not show improvement • Ismail H, McFarlane JR, Nojoumian AH, et al. “Clinical Outcomes and Cardiovascular Responses to Different Exercise Training Intensities in Patients with Heart Failure” JACC Heart Fail 2013; 1(6): 515-522

34. VARIOUS EXERCISE INTENSITIES • Ismail H, McFarlane JR, Nojoumian AH, et al. “Clinical Outcomes and Cardiovascular Responses to Different Exercise Training Intensities in Patients with Heart Failure” JACC Heart Fail 2013; 1(6): 515-522

35. VARIOUS EXERCISE INTENSITIES • Higher intensity groups increased VO2 the most • Higher peak VO2 equals lower mortality • NO DEATHS with over 123,000 patient hours of exercise training!! • Higher intensity exercise is safe and effective

36. WOMEN AND CHF • Women showed similar increases in peak VO2 as men • However, women had larger decrease in hospitalization and larger reduction in all cause mortality. • Pina IL, Bittner V, Clare RM, et al. “Effects of Exercise Training on Outcomes in Women with Heart Failure: Analysis of HF-ACTION by Sex” JACC Heart Fail Published online February 26, 2014.

37. EXERCISE PRESCRIPTION F.I.T.T. PRINCIPLE • Frequency • Intensity • Time • Type

38. EXERCISE PRESCRIPTION FREQUENCY • 3 Days per week initially • Build up to 4-5 days per week

39. EXERCISE PRESCRIPTION INTENSITY • RPE Scale • Dyspnea • Heart Rate

40. 6 7 very, very light 8 9 very light 10 11 light 12 13 somewhat hard 14 15 hard 16 17 very hard 18 19 very, very hard 20 EXERCISE PRESCRIPTION INTENSITY RPE SCALE

41. EXERCISE PRESCRIPTION INTENSITY DYSPNEA SCALE (Modified Borg) 0 None 5 Severe 0.5 Very, Very slight 6 1 Very slight 7 Very Severe 2 Slight 8 3 Moderate 9 Very, Very Severe 4 Somewhat severe 10 Maximum

42. EXERCISE PRESCRIPTION INTENSITY HEART RATE • 40% to 85% of HR reserve method • Start slowly and progress slowly • Progress to 60 to 85% of HR reserve • Beware of failure of HR to rise appropriately! • With increased HR’s use interval training

43. EXERCISE PRESCRIPTION

44. EXERCISE PRESCRIPTION TIME • Initially 10 to 20 minutes • 20 to 40 minutes/session • May have to use shorter bouts (2-6 mins) more frequently with 2 to 4 minute rest periods

45. EXERCISE PRESCRIPTION TYPE • Aerobic Interval Training

46. Exercise Prescription is an Art!! Every patient is different EXERCISE PRESCRIPTION

47. REFERENCES • Ades PA, Keteyian SJ, Balady GJ, Houston-Miller N, et al. “Cardiac Rehabilitation Exercise and Self-Care for Chronic Heart Failure” JACC Heart Fail 2013;1(6): 540-547 • Go AS, Mozaffarian D, Roger VL, et al. “Heart Disease and Stroke Statistics 2014 Update: A Report From the American; Heart Association” Circulation 2014 129: e28-e292 • Ismail H, McFarlane JR, Nojoumian AH, et al. “Clinical Outcomes and Cardiovascular Responses to Different Exercise Training Intensities in Patients with Heart Failure” JACC Heart Fail 2013; 1(6): 515-522

48. REFERENCES • Mezzani, A, Hamm, LF, Jones AM, et al. Aerobic Exercise Intensity Assessment and Prescription in Cardiac Rehabilitation: A Joint Position Statement of the European Association for Cardiovascular Prevention and Rehabilitation, The American Association of Cardiovascular and Pulmonary Rehabilitation, and the Canadian Association of Cardiac Rehabilitation. JCRP 2012; 32(6): 327-350 • O’Connor CM, Whellan DJ, Lee KL, et al. “Efficacy and Safety of Exercise Training in Patients with Chronic Heart Failure: HF-ACTION Randomized Controlled Trial” JAMA 2009; 301(14): 1439-1450 • Pina IL, Bittner V, Clare RM, et al. “Effects of Exercise Training on Outcomes in Women with Heart Failure: Analysis of HF-ACTION by Sex” JACC Heart Fail Published online February 26, 2014.