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Heart Failure: Cardiac

Rehabilitation Program
EXP 590 Final Project
Kelly Van Berkel
Summer 2015

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Introduction
Chronic heart failure is characterized by an intolerance to exercise. With this
particular group of patients, they often experience early fatigue and shortness of breath.
Such symptoms impact upon ones ability to perform activities of daily living, thus
greatly contributing to reduced participation and poor quality of life. In an attempt to both
improve outcomes for this population and reduce the significant economic burden
imposed upon the health care system, designated heart failure services, such as
cardiac rehabilitation, have recently been established (2,5,7,13).
Before 1980, exercise was considered unsafe for patients with heart failure. It
was uncertain whether any benefit could be gained from rehabilitation. Another concern
about safety was the belief that harm would come from the additional myocardial stress
of exercise. Since this time, particularly in the past decade, numerous studies have
documented the safety and benefits of exercise for individuals living with chronic heart
failure (1,2,18). Improving ones ability to perform low-level activities can mean the
difference between continuing to work and live independently and becoming disabled.
The key to maximizing the benefits of exercise is to follow a well-designed program that
accommodates with patients specific needs and concerns (9,11,15).
Currently at Coulis Cardiology we have minimal referrals from our physicians for
heart failure patients who actually qualify for cardiac rehabilitation by Medicares
guidelines. By reviewing the research on the benefits verses the risk of these patients in
cardiac rehabilitation, along with the best protocols and prescription for heart failure we
hopefully can start to develop and implement our own heart failure program that will be
utilized and effective.
Supporting Research
As stated previously, Heart failure may be defined as the inability of the heart to
meet the demands of the tissues, which results in symptoms of fatigue or dyspnea on
exertion progressing to dyspnea at rest (13). The inability to perform exercise without
discomfort may be one of the first symptoms experienced by patients with heart failure
and is often the primary reason for seeking medical care. Therefore, exercise
intolerance is inextricably linked to the diagnosis of heart failure. It might be expected
that a tight relationship would exist between indices of resting ventricular function and
exercise capacity. However, research has shown that indices of resting function are only
weakly correlated to exercise tolerance (12). Exercise intolerance is defined as the
reduced ability to perform activities that involve dynamic movement of large skeletal
muscles because of symptoms of dyspnea or fatigue (7,13,22). Many researchers have
sought mechanisms to explain the source of exercise intolerance. Although the primary
pathology of heart failure results from abnormalities in cardiovascular function,
abnormalities in peripheral blood flow, skeletal muscle morphology, metabolism,
strength, and endurance all contribute to the heart failure syndrome. Several trials have
shown that cardiac rehabilitation improves disease-related symptoms, quality of life, and
clinical outcomes (3,8). Overall, prescribed exercise decreases the fatigue and dyspnea
that limit exercise intolerance. The improvements ranged from 15 to 30% in peak VVO2,
which is greater than or equal to the gains in exercise capacity observed in many
clinical drug trials (7,10,11).

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Numerous mechanisms contribute to improved functional capacity in patients


with heart failure who participate in cardiac rehabilitation. Essential hemodynamic
mechanisms include increases in peak cardiac output, heart rate, and stroke volume
(11,13,18). Peripheral mechanisms include improved endothelial vasodilator function,
increased cellular oxidative enzyme activity, a greater oxygen extraction from the blood,
and an improved neurohumoral axis. These peripheral adaptations result in an
increased oxygen delivery or utilization in the more active skeletal muscle, thus delaying
the anaerobic response (2,18,22). Exercise has beneficial effects on skeletal muscle by
improving function, histologic, and biochemical characteristics. Exercise also affects the
muscle by reducing the activation of its ergoreceptors (1,18). A 10-week study
demonstrated the benefits of strength training in older women with chronic heart failure.
The mean age of the training group was 77 years, the average left ventricular ejection
fraction was 36%, the average classification for the women was New York Heart
Association (NYHA) class 2.2 and the length of diagnosis with heart failure averaged
three and a half years. The gains in functional performance following strength training
corresponded directly to the improvement in the muscles metabolism and function.
However in this study strength training did not alter resting cardiac function, proposing
that peripheral adaptations facilitated the increased exercise performance. Although
maximal exercise tolerance is an important outcome in patients with heart failure,
equally if not more important is their ability to perform the activities of daily. This study
correlates directly with many similar studies on submaximal performance (9).
Many other studies showed that exercise training in patients with heart failure is
associated with improvements in shortness of breath, the ability to perform activities of
daily living, anxiety, depression, and general well being. The magnitude of improvement
in quality-of-life parameters ranged between 15% and 50% (8). After 2 months of
exercise training one study found improvements with a Heart Failure Questionnaire and
the benefits continued at the 14-month of follow-up. Improvements in quality of life
correlated to the increases in peak VVO2 (5). The European Heart Failure Training Group
also reported results from a total of seven centers involving 134 patients and confirmed
the beneficial effects of exercise rehabilitation on functional capacity (18).
Although adverse events directly related to exercise training are infrequent,
patients still can experience complications because of their overall increased risk due to
left ventricular dysfunction. To enhance safety of new exercisers, patients should
undergo a period of supervised exercise to evaluate for any potential complications.
This is where supervision and monitoring in cardiac rehabilitation helps to reveal
possible unnoticed signs and symptoms, such as weight gain, decreased exercise
capacity, and arrhythmias. Quick and timely intervention often can prevent
hospitalization for decompensated heart failure patients (1,18).
Another area to consider is recurrent symptoms and hemodynamic
decompensation, which are leading causes of hospital readmission. One study showed
that heart failure patients in cardiac rehabilitation reduced readmissions by 19% and
mortality by 22%. In stable patients with chronic class II and III heart failure who
participated in exercise training programs for at least 14 months, their survival was
prolonged by an additional 1.82 years, In addition, exercise training programs are
effective. The cost of $1,773 per life-year was saved in the exercise group compared
with non-exercising control subjects, the cost-effectiveness for cardiac rehabilitation is

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imperative (23). Now more work and research is needed to help clinicians to identify
which heart failure patients are most likely to gain maximum benefits from exercise and
to determine whether severity of illness, etiology of illness, age, gender, or other factors
influence physiologic or clinical outcomes due to the exercise training.
Importance
Chronic heart failure is highly prevalent in older individuals and is a major cause
of morbidity, mortality, hospitalizations, and disability (23). Cardiac rehabilitation
exercise training and heart failure self-care counseling have each been shown to
improve clinical status and clinical outcomes those with this condition (8,23). There is
plenty of research and reviews on cardiac rehabilitation and exercise training alone that
have shown improvement in heart failure symptoms, along with reductions in cardiac
mortality and number of hospitalizations (9).
The studies that address quality of life of heart failure patients participating in an
exercise program are limited. When it comes to quality of life, the most commonly used
questionnaire is the Minnesota Living With Heart Failure Questionnaire. This
questionnaire assesses disease-specific health-related quality of life by including the
patients perceptions of the effects of heart failure and its treatment on ones daily life. In
these studies (3,8) they demonstrated significant improvement in exercise capacity and
in most measures of quality of life in the patients who were randomly assigned to the
exercise-training group. One key factor to consider, though, is the limited research
examining quality of life in patients with heart failure who have participated in exercise
training. However, with the limited data, the studies that were performed supported that
cardiac rehabilitation increased the quality of life of those heart failure patients through
their multi-interventional programs (8).
A large study done by the Heart Failure Action Team showed a reduction in the
regulated risk for the combined endpoint of all-cause mortality or hospitalization with a
95 percent confidence interval (12). Quality of life and mental depression also improved.
Heart failure related counseling, both individually and/or in a cardiac rehabilitation
exercise session improved clinical outcomes and reduced heart failure related
hospitalizations. The next step would be to assess the role of cardiac rehabilitation to
promote self-care and behavioral changes (5). Another study reported the results of the
effectiveness of exercise-based interventions on the mortality, hospitalization
admissions, morbidity and health-related quality of life for patients with systolic heart
failure of 19 trials with 3647 heart failure patients combined. In this study exercise
based interventions and comprehensive cardiac rehabilitation with follow up time of at
least six months were included. The population included adults with heart failure based
on clinical diagnosis and objective measures such as ejection fraction, with an average
age ranging from 43 to 72 years. A reduction in the hospitalization rate was shown as a
result with exercise training programs. Hospitalizations due to systolic heart failure were
also reduced with exercise and there was a significant improvement in health-related
quality of life. The effect of cardiac exercise training on total mortality and quality of life
was independent of the degree of heart failure, type of cardiac rehabilitation, dose of
exercise intervention, and length of follow up. They concluded: This review provides
evidence that in a similar population of patients, exercise does not increase the risk of

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all-cause mortality and may reduce heart failure-related hospital admissions. Exercise
training may offer important improvements in patients health-related quality of life (8).
One study conducted by OConnor was to test the efficacy and safety of exercise
training among patients with heart failure. Inclusion criteria included LVEF 35% and
NYHA class II-IV despite optimal therapy for at least six weeks. The exercise-training
program consisted of a structured, group-based, supervised exercise program, with a
goal of 3 sessions per week for a total of 36 sessions in 3 months. Followed by homebased exercise five times per week for 40 minutes. Participants in the usual care group
of this study did not receive formal exercise prescriptions. All patients with in the study
received detailed self-management educational materials. A post hoc analysis was also
piloted between the study and control groups to compare the compound of
cardiovascular mortality, heart failure hospitalization, left ventricular assist device
implantation, or heart transplantation. Overall it was concluded that the performance of
exercise training was well tolerated and safe for heart failure patients. Due to there
being no significant reductions in the exercise training group for mortality or
hospitalization compared to the usual care group (15,16).
Another study similar to the previous was completed by Belardinelli, who looked
to determine whether a 10-year supervised moderate cardiac rehabilitation program
may produce a sustained improvement in functional capacity and quality of life in New
York Heart Association class II and III chronic heart failure patients. Inclusion criteria
were heart failure patients that were clinically stable for 3 months before enrollment, left
ventricular ejection fraction less than 40%, and patients who were able to exercise.
Primary assessments included peak oxygen consumption and change from baseline in
quality of life using the Minnesota Living with Heart Failure Questionnaire. All-cause
mortality and cardiovascular morbidity, requiring hospitalization and adjustment of
medications, unstable angina, myocardial infarction, and cardiac revascularization
procedures were also considered outcomes. The program consisted of three sessions
per week at the hospital for 2 months, then 2 supervised sessions the rest of the year by
a cardiologist and exercise therapist. With this study it was concluded that supervised
cardiac rehabilitation performed twice weekly for 10 years maintains functional capacity
of more than 60% of maximum VO2 and confers a sustained improvement in quality of
life compared with non exercise patients. These sustained improvements are
associated with reduction in major cardiovascular events, including hospitalizations for
chronic heart failure and cardiac mortality (4).
Another study done by Witham and colleagues reported on whether an exercise
program tailored to the needs of Heart Failure patients could improve exercise capacity
and quality of life or reduce costs to the National Health Service. The inclusion criteria
included an age greater than or equal to 70 years, NYHA class II and III, left ventricular
systolic dysfunction and signs and symptoms of congestive heart failure. The primary
assessment was a six-minute walk distance and again at 24 weeks. Secondary
assessments included physical function, Minnesota Living With Heart Failure
questionnaire, health status, and daily activity. The intervention program including
aerobic and strength training, performed twice a week at an exercise class for eight
weeks in an outpatient group setting was led by a physiotherapist. This was followed by
16 weeks of home exercise program. This unfortunately stated no significant difference
between groups for the primary outcome and quality of life at 24 weeks, concluding that

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an exercise intervention did not improve exercise capacity or quality of life in older
patients with heart failure (23).
The benefits of exercise training in patients with heart failure include an
improvement in exercise tolerance not only by exercise duration but also by peak VVo2,
mortality and hospitalization rates, quality of life, and many other factors that were
repeated shown through the research and studies. Though these exercise-training
programs have varied by such factors as setting, mode of exercise, duration, and
intensity, there is still one common theme and that cardiac rehabilitation is beneficial for
heart failure patients (5,9,11).
Risks
There are many factors that affect the risk of exercise. Three important factors
related to heart failure are age, the presence of heart disease, and intensity of exercise.
Sudden cardiac death during exercise is uncommon in apparently healthy individuals.
Persons with cardiac disease, though, have shown to be at greater risk for sudden
cardiac arrest during vigorous exercise compared to their healthy counterparts. The
incidence of major cardiovascular complications during outpatient cardiac exercise
programs has been estimated to be 1 in 60 000 participant-hours (9,11,21). In a rehab
setting the type and intensity of exercise and the use of monitoring affect occurrence of
sudden cardiac arrest. In cardiac patients, the incidence is lowest during activities that
are largely controlled, such as walking or cycling. Activities performed with continuous
ECG monitoring also have the lowest rates of sudden cardiac arrest compared with
those that are unmonitored or only intermittently monitored (2,5).
Myocardial infarction is another risk associated with participation in exercise and
is more likely to occur than sudden cardiac death. Roughly 4 to 20 percent of
myocardial infarctions occur during or soon after physical exertion. However, the risk
has been found to be greater in persons who do not regularly participate in physical
activity (5,9).
Overall patients with chronic heart failure have greater overall morbidity and
mortality rates than those of healthy persons and people with most other forms of heart
disease. Hence, current practice guidelines stratify those patients with heart failure at
the highest level of risk. The most common events in such patients include post
exercise hypotension, atrial and ventricular arrhythmias, and worsening heart failure
symptoms. The adverse event rates in studies of patients with heart failure who
performed home exercise are also low (3). Patients with chronic heart failure can
participate in a supervised training program for a brief time to obtain instructions for selfmonitoring before proceeding with a program of unsupervised exercise. A brief
supervised period will serve to enhance patient confidence in his or her ability to
exercise effectively and safely (9).
Musculoskeletal injuries are also common and can include direct injuries such as
bruises, sprains, and strains along with indirect problems such as arthritis and back
pain. Low-impact exercises such as walking, cycling, and swimming cause little to no
stress on bones and joints, whereas high-impact exercises such as running and dancing
can cause high stress and impact on the knees, ankles, and feet. Studies of injuries
during exercise indicate that intensity and biomechanical impact of the activity

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performed are the two most important factors in determining the frequency of injuries
(22).
Although there have been major advances in heart failure rehabilitation, it is clear
that medications alone should not be the only answer to this condition. After the initial
period of intervention, heart failure patients need continuous long-term support outside
the hospital environment. Therefore, it is important to promote and implement
individualized discharge planning, exercise and continued patient education. Cardiac
rehabilitation is that ideal comprehensive, structured disease intervention along with
core components of cardiac rehabilitation should include baseline clinical assessment
and risk stratification, pharmacological therapy prescribed by physician, management of
heart failure related diseases, and a continuing program of physical activity, exercise
training, counseling and education, and psychological support (5,6,20). Heart failure
patients should attend a rehabilitation program as soon as they are discharged from
acute care institutions to assure clinical stability and to prevent hospitalizations. The
future challenge is to promote strategies to increase participation in cardiac
rehabilitation programs and to incorporate this management approach into future health
care planning in an effort to deal with the current epidemic of heart failure.
Methods
Intervention
In order to implement a heart failure program within our cardiac rehabilitation
services the first step is to develop the best protocols to be used, aerobic, resistance,
and flexibility/balance. After we have a set program for this specific population we can
then review doctors current clientele diagnosed with heart failure and assess if they
qualify by Medicare guidelines for a billable diagnoses, these qualifications are listed in
procedures. Another key factor is to make the doctors and medical staff aware of these
diagnoses so they can then refer them to our program. A chart will be developed to
hang in each examination room to make staff aware. Once patients are referred we can
schedule an orientation and baseline assessments. As stated earlier this program will
be more individualized to each patient due to the complicated nature of this condition.
Further information on this can be seen in the protocol section, on program length, and
F.I.T.T. principles.
Outcomes and Value
Heart failure, again, is a common and costly condition, particularly in the elderly.
A range of models of interventions has shown the capacity to decrease hospitalizations
and improve health-related outcomes. Potentially, cardiac rehabilitation models can also
improve outcomes and that is what wed like to see after implementing our program at
Coulis Cardiology. Another outcome we would like to see is an increase in staff
awareness and diagnosis referrals to our program. The value of implementing such a
program would not only be cost effective for the patients but the clinic as well. Being
able to recognize the impact of a multidisciplinary, cardiac rehabilitation program to
decrease hospitalizations, increase functional capacity, and meet the needs of patients
with heart failure as they do other heart conditions is essential especially due to the
recent high rates of diagnosis of heart failure.

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Procedures
Before a patient can even be considered for the cardiac rehabilitation program
the patient must meet the eligibility criteria. In order to participate patients must have
stable, chronic heart failure meeting all of following:
Left ventricular ejection fraction < 35%
NYHA class IIIV symptoms despite being on optimal heart failure therapy for at least
6 weeks
Stable heart failure means that the patient has not had recent, less than six weeks,
or planned, less then six months, major cardiovascular hospitalizations or
procedures
Stable, chronic heart failure is defined as the following:
Stable means the patient's symptoms from heart failure are not worsening relatively
rapidly, requiring prompt evaluation for medication adjustment or procedures.
Although patients with heart failure can have good days and bad days progressive
declines in functional capacity due to fatigue or dyspnea or rapid increase in edema
or weight may be symptoms of medical instability.
Optimal, chronic heart failure is defined as the following:
Medical therapy varies; depending on a patient's tolerance for medications, but in
general includes a beta-blocker such as carvedolol or metoprolol and an ACEI or
ARB.
Referring physicians will understand the concepts of stable and optimal medical
therapy, as they relate these terms to patients with heart failure (9).
Cardiac rehabilitation is characterized by a continuum of services that spans
inpatient and outpatient rehabilitation. Inpatient rehabilitation should begin as soon as
possible after hospital admission; every eligible heart failure patient should receive
appropriate strategies for optimal therapy and have access to an individualized program
and, when possible, group education, according to clinical assessment and risk
stratification. Education should be interactive with full participation of patient, each
intervention should be explained and the early mobilization program should vary
according to individual needs and hospital protocols. Progression of mobilization should
be developed according to the patient's clinical condition, functional capacity, age,
comorbidity with careful medical review and supervision. Education, reassurance and
support, and mobilization should be part of routine daily care for every heart failure
inpatient (5,6,9,11).
As the length of stay for acute heart failure and procedures continues to
decrease, patient and family attendance in outpatient cardiac rehabilitation programs
assumes even greater importance. Structured outpatient cardiac rehabilitation, either
residential or ambulatory, is crucial for the development of a life-long approach to
prevention. Attendance will be expected to start soon after discharge from the hospital,
ideally within the first few days. Different heart failure management programs have been
illustrated, and their content and the effectiveness of interventions vary widely but we
will utilize a guidelines developed by the clinics exercise physiologists and cardiologist
(2,5,8,9). Though outpatient cardiac rehabilitation may be provided in a range of
settings, such as heart failure clinics and non-clinic settings such as community health
centers or general medical practices, or a combination of these or care will be provided

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through our cardiac rehab or wellness programs (5). The main elements of outpatient
cardiac rehabilitation that will be included are assessment, review and follow up, low or
moderate intensity physical activity, exercise training, education, discussion and
counseling (11,20,21).
Prior to starting an exercise program, our patients with chronic heart failure will
go through a comprehensive evaluation to assess risk stratification. These patients
cannot be considered in the same manner as our other patient populations due to the
fact that normal physiological responses to exercise are blunted and abnormal, patients
may be on multiple medications specific to this population which may have an impact
upon the exercise responses, the risk of sudden cardiac death and frequency of other
arrhythmias requires specific attention regarding safety procedures and level of
supervision as stated earlier, along with patients commonly having multiple medical
comorbidities that impact upon exercise capabilities (2,11,19, 21).
Equipment
Equipment used will be dependent on the patients risk and condition. In our
facility we have an array of aerobic and resistance equipment that can be utilized. For
aerobic equipment we have treadmills, nu-steps, arm ergometers, recumbent bikes, air
dynes, physiosteps, elliptical, and few others. For resistance training we have
resistance bands, free weights, a multigym, and various equipment such as medicine
and physioballs. For flexibility there is also a mat that can be laid out in an open area.
Other equipment that will be utilized will be our Quinton monitoring system, since
research showed better results when patient were continuously monitored that is
something I would implicate as best practice. Our monitors are a simple five lead holter
monitoring system that patients apply four electrodes and monitor hangs from a pouch
around their neck. Additional equipment would include any of the cardiac rehabilitations
emergency equipment and monitoring systems.
Protocols
The Aerobic F.I.T.T Principle
The general principles for exercise training are summarized by the FITT principle;
frequency, intensity, time and type. Guidelines for each of these parameters remain
relatively vague due to the fact that research has not adopted or found such variable
study designs in which a correlation has been found to exist between any individual
parameter and/or functional outcome (2,5,6). In this case a combination of best practice
will be implemented for our program at Coulis Cardiology from AACVPR, Queensland
pathways home project, CCS, ACSM, and CMS guidelines and recommendations.
Frequency and Duration
Much of the time exercise outcomes are considered to be dose dependent. This
has independent factor has been shown to be the case for patients with heart failure.
The frequency and duration of exercise prescribed for each individual should be tailored
to their functional ability. Those more incapacitated patients should exercise for a
shorter duration though doing so more frequently, for example high intensity interval
training (HIIT). This allows for greater recovery time while performing the same or

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greater total volume of exercise. Current recommendations, that we will use, suggest a
minimum frequency of 3-5 days per week starting at short durations of 10-20 minutes
and progress to longer session times of 30- 40 minutes (11). For each individual patient
we will work off of this guideline. Duration of the rehabilitation program has also been
shown to be an important factor. Greater functional gains have been seen with longer
program training durations. This is due to the general trend of decreased physical
activity once program has ended. Because of this and due to the nature of the condition,
programs of longer duration than traditional cardiac rehabilitation programs are
recommended in this population. This is seen as necessary in order to effect significant
change and to slow the rate decline in patients with this condition (2,11,21). However,
Medicare guidelines will only allow a max of 36 sessions and then we can offer these
patients either of our wellness programs to continue monitored exercise.
Intensity
For intensity there has been no clear relationship found between exercise and
functional capacity. In multiple studies training benefits have occurred at intensities
ranging from 40-85% peak VO2 (2,11). Given the research a 40-80% peak VO2 or heart
rate reserve is the intensity that will be used for our heart failure rehabilitation program.
Patients should also exercise at a rating of perceived exertion between 9-14 on the 6-20
RPE scale (11,21).
Type
There are many studies with a variety of designs when it comes to type of
exercise performed. Some have included individual activities such as cycle ergometer
or treadmill, while others have used a combination of modes of exercise such as cycle
ergometer plus additional activities such as rowing machines, step aerobics or
calisthenics. There is some evidence that more comprehensive programs including a
combination of activities may be more beneficial than one activity alone but the goal
should be dynamic activities involving large muscle groups (2,11). With this being said
within our program patients will be using any of the aerobic equipment; treadmills, nusteps, cycles, etc. depending on their own limitations and needs. Aerobic training for
patients with chronic heart failure, depending on their condition may be prescribed as
steady state or intermittent training. Both intermittent and continuous protocols have
shown to be of significant benefit to heart failure patients. Within our program we will
implement the protocol depending on the class and staging of the heart failure. Recent
studies have also been investigating the benefits of combining aerobic training with
other modes of exercise such as resistance training (2,11,21). Given this research we
will then implement resistance training when patients are ready.
Other considerations
Even with recent evidence in the area of exercise and chronic heart failure,
numerous questions remain unanswered. Further research should continue to look at
women specifically and heart failure, frail patients, NYHA class, and those with less
stable of a condition (11,21).

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Resistance Training
Before the current guidelines, resistance training was not recommended for
patients with heart failure due to its perceived association with undesirable
hemodynamic responses. Through research we now know this is not the case when it
comes to skeletal muscle (11). Resistance training aims to counteract a number of the
peripheral adaptations previously described. For this reason the inclusion of resistance
training will be implemented as a part of the exercise prescription being prescribed for
these patients in cardiac rehabilitation (2,11,21).
Frequency and Duration
When it comes to frequency of a resistance program it is completely dependent
on the condition of the patient. For patients that are classified as NYHA II or III they
should be performing these exercises 1-2 days/ week and 2-3 days/week for NYHA I
classes. Sessions should last 20-30 minutes per session and contractions should be
performed in a rhythmic manner at a moderate to slow controlled speed. Each exercise
should start at one set of 8-15 reps progressing to 2-4 sets (2,11). These guidelines will
be utilized for patients that are ready for this level of exercise, along with a recovery
period, this ratio is work/1: recovery/2 (2,11).
Intensity
For intensity of resistance training it differs depending on the severity of the
condition. The typical range for the workload that will be utilized by our program for the
lower body should be 50 to 70 percent of patients one rep max. For the upper body the
range is 40 to 70 percent of the one rep max. Patients will also exercise at a rating of
perceived exertion between 9-13 on the 6-20 RPE scale (2,11,21).
Type
For type of exercise it really depends on the preference and condition of the
patient. There are many studies using a variety of types of exercises but all have shown
to be beneficial. A resistance workout for our heart failure patients will consist of 8-10
muscle specific exercises involving resistance bands, weights machines, handheld
weights, or a combination (11,21).
Analyses
Chronic heart failure is a progressive illness characterized by multiple
physiological changes that impair exercise capacity and induce functional decline over
time. The aim of a specific heart failure program is not to significantly increase aerobic
capacity or muscle strength but to maintain and reverse or delay those physiological
changes that take place within this population. Resistance exercise is considered safe,
and in combination with aerobic training, is recommended for all rehabilitation programs
for patients with heart failure. Again further research needs to be done to create a larger
population for this particular condition. These areas should include frail elderly, NYHA
classes I and IV, among many other sub categories (2,11).

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Although a variety of disease management strategies with appropriate discharge


planning and post-discharge support can, in the hands of experienced healthcare
professionals, work in high-risk heart failure patients. Patient education to enhance selfcare, follow-up monitoring by specially trained staff, and access to specialized heart
failure clinics seem the most effective approaches (6,17). The need for a continuum of
care is clear and the program of self-care and prevention of lapses, recurrences and
readmissions should be life-long. Evaluation of ongoing cardiac rehabilitation program
objectives on a regular basis is a key to success. This is where our monitored wellness
programs may be beneficial for these patients and separate our program from others.
The recommended model for cardiac rehabilitation is delivered by a multidisciplinary
team: team members have different backgrounds and training and therefore different
areas of expertise. A designated program coordinator is essential to ensure efficient
running of the rehabilitation program. The program and medical director should be a
cardiologist with good organizational, management and interpersonal skills (2,9,11,21).
In our case the lead doctor has taken on this role and is working with me in developing
a program that will actually be cost effective and utilized.
Results
Once more heart failure may be defined as the inability of the heart to meet the
demands of the tissues, which results in symptoms of fatigue or dyspnea on exertion
progressing to dyspnea at rest (13). The inability to perform exercise without discomfort
may be one of the first symptoms experienced by patients with heart failure and is often
the primary reason for seeking medical care. Therefore, exercise intolerance is
indistinguishably linked to the diagnosis of heart failure. It might be expected that a tight
relationship would exist between the key factors of resting ventricular function and
exercise capacity. However, research has shown that indices of resting ventricular
function are only weakly correlated to exercise tolerance. Exercise intolerance is
defined as the reduced ability to perform activities that involve dynamic movement of
large skeletal muscles because of symptoms of dyspnea or fatigue (7,13,22). Many
researchers have pursued the mechanisms to explain the source of exercise
intolerance. Although the primary pathology of heart failure results from abnormalities in
cardiovascular function, abnormalities in peripheral blood flow, skeletal muscle
morphology, metabolism, strength, and endurance all contribute to the heart failure.
Several trials have shown that cardiac rehabilitation improves disease-related
symptoms, quality of life, and clinical outcomes (7,10,11). With there being limited time
we did not necessarily have enough data to verify and compare the outcomes of
previous research but the results we did have were significant, even with being more
qualitative; which, led to many other beneficial developments to profit the practice.
Our first goal of developing implementing a cardiac rehabilitation program for
heart failure patients that was cost effect and utilized has developed immensely, and led
to an option for after care for these patients. If anything by making this program will
profit Coulis Cardiology by allowing them to take on a more varied clientele and stay
competitive with larger hospitals programs. Another way that the clinic is profiting from
developing this program is through the development of the advanced wellness program
that was developed in order to support those patients that do not meet Medicare eligibly
guidelines or co-pays are to taxing.

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This new program leads directly to the next outcome of increasing the staffs
awareness and diagnoses for cardiac rehabilitation. This was done by developing a
chart to hang in all of the patient rooms along with the nurses stations, that gave all
billable codes for cardiac including heart failure and its criteria (see Appendix A). This
simplistic but yet effective promotion of the new diagnosis was very beneficial. This can
be seen in the graph in Appendix B. With the amount of heart failure patients verses the
total patients that were eligible through Medicare guidelines. Within the three months of
developing this program for Coulis Cardiology we saw an increase of only 6% of heart
failure patients being enrolled verses eligible patients in June to 35% of those patients
being enrolled by mid-August. As more patients are enrolled in these programs future
analysis can be done on outcomes and cost effectiveness. With this being newer
Medicare diagnosis regulations may continue to change so it is important that the
program stays active in order to benefit those multiple patients with heart failure.
Discussion
People with heart failure can experience significant reductions in their activities of
their daily living and health-related quality of life because of their restricted heart
capacity. This can reduce their ability to exercise, which can further reduce fitness
making their symptoms worse. Chronic heart failure is also associated with a
substantially increased risk of death. By implementing a cardiac rehabilitation program
specifically for heart failure patients at our clinic will not only help our patients both short
and longer term, with research attesting improved health-related quality of life and VO2
peak compared to usual care, along with cost effectiveness for both patient and hospital
due to minimizing readmissions from exacerbated symptoms. Overall by developing a
solid program will only profit Coulis Cardiology and its care for their patients. Though we
could not see total results until recently. We did see greater numbers within our program
and within the future analysis could be done on progression and improvements of
patients within the program. Along with making improvements as the care for these
patients continues to grow.
Limitations
There were multiple limitations to this study. One being that there was limited
data on heart failure and the benefits of cardiac rehabilitation, nonetheless the limited
guidelines for an actual heart failure program. With this limited data it was hard to
implement the best practice for these patients. Another limitation is the doctors still
being unaware to the available diagnosis to help these patients with the charts made.
The doctors in our program started referring every heart failure patient to cardiac rehab
whether they met guidelines or not. This began to become problematic when patients
are expecting to get help and we have to reject them. To help these patients that did not
meet criteria, we developed an advanced wellness program where monitoring of heart
rate, blood pressure, and rhythm for initial sessions, midpoint of year, then last sessions
of year would be done. This program would be very beneficial for heart failure patients
or other patients that are high risks and dont have a billable diagnoses. A last limitation
was the time frame to apply such a program. This was a limitation due to there not
being enough resources to review patients charts and really promote our program to
staff.

K.VanBerkel, 14

Conclusion
Although there have been major advances in heart failure rehabilitation, it is clear
that medications alone should not be the only answer to this condition. After the initial
period of intervention, heart failure patients need continuous long-term support outside
the hospital environment. Therefore, it is important to promote and implement
individualized discharge planning, exercise and continued patient education. Cardiac
rehabilitation is that ideal comprehensive, structured disease intervention along with
core components of cardiac rehabilitation should include baseline clinical assessments
and risk stratification, pharmacological therapy prescribed by physician, management of
heart failure related diseases, and a continuing program of physical activity, exercise
training, counseling, education, and psychological support (5,6,20). Heart failure
patients should attend a rehabilitation program as soon as they are discharged from
acute care institutions to assure clinical stability and to prevent hospitalizations.
The future challenge for this program is to promote strategies to increase
participation in cardiac rehabilitation programs and to incorporate this management
approach into future health care planning in an effort to deal with the current epidemic of
heart failure.

K.VanBerkel, 15

Appendices
Appendix A: Cardiac Rehabilitation Medicare Billable Diagnoses Chart
Appendix B: Graphed Results
Appendix C: References

K.VanBerkel, 16

Appendix A
Code
V45.81
V45.82
V43.3
410.9
413.9
42.1
Codes will be put
in by Dr. There are
a variety of codes
that can billed.
(428.0, 428.23, etc.)

Description
S/p CABG (within 6 months)
S/p PTCA (within 6 months)
S/p Valve Replacement/Repair
S/p MI (within 6 months)
Stable Angina (Well documented)
S/p Heart Transplant
Heart Failure - Must meet criteria. EF 35% or less AND NYHA
class II-IV symptoms despite being on optimal HF therapy for
at least 6 weeks. Stable patients are defines as not having had
recent (6 weeks) or planned (6 months) major
cardiovascular hospitalizations or procedures (oftentimes they
will have had CABG/PTCA --- which would then qualify them
for rehab anyways).

** Note: Some private insurance companies/ non-Medicare will approve codes other
than what is listed above. If the doctor refers them for CR and the code is not listed and
Medicare is not their insurance company, we can call to see if they would allow the code
used by the doctors. **

K.VanBerkel, 17

Appendix B

Patients Enrolled Versus Total Elgible

August

HF Pts
Enrolled
Month

July

Percentage

June

The graph represents the number of patients enrolled verses the total patients that are eligible
for rehabilitation for heart failure throughout the course of the summer of 2015 (June 1st
August 10th). In the month of June there was one patient enrolled verse the 15 eligible giving a
percentage of 6.7%. For the month of July there was three patients enrolled compared to the 14
eligible, giving a percentage of 21.4%. The last month of August there was a total of six patients
enrolled for the heart failure program out of the 17 eligible, ending the summer at a 35.3% of
patients enrolled.

K.VanBerkel, 18

Appendix C
References
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Chronic Heart Failure. Pathways Home Project.
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from a randomized controlled trial of cardiac rehabilitation for heart failure. Eur J
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K.VanBerkel, 19

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