Impact of Physical Inactivity on Mortality in Patients With Heart Failure

doi:10.1016/j.amjcard.2015.12.060

The American Journal of Cardiology

Volume 117, Issue 7, 1 April 2016, Pages 1135-1143

https://doi.org/10.1016/j.amjcard.2015.12.060 Get rights and content

The impact of physical inactivity on heart failure (HF) mortality is unclear. We analyzed data from the HF Adherence and Retention Trial (HART) which enrolled 902 patients with New York Heart Association class II/III HF, with preserved or reduced ejection fraction, who were followed for 36 months. On the basis of mean self-reported weekly exercise duration, patients were classified into inactive (0 min/week) and active (≥1 min/week) groups and then propensity score matched according to 34 baseline covariates in 1:2 ratio. Sedentary activity was determined according to self-reported daily television screen time (<2, 2 to 4, >4 h/day). The primary outcome was all-cause death. Secondary outcomes were cardiac death and HF hospitalization. There were 196 inactive patients, of whom 171 were propensity matched to 342 active patients. Physical inactivity was associated with greater risk of all-cause death (hazard ratio [HR] 2.01, confidence interval [CI] 1.47 to 3.00; p <0.001) and cardiac death (HR 2.01, CI 1.28 to 3.17; p = 0.002) but no significant difference in HF hospitalization (p = 0.548). Modest exercise (1 to 89 min/week) was associated with a significant reduction in the rate of death (p = 0.003) and cardiac death (p = 0.050). Independent of exercise duration and baseline covariates, television screen time (>4 vs <2 h/day) was associated with all-cause death (HR 1.65, CI 1.10 to 2.48; p = 0.016; incremental chi-square = 6.05; p = 0.049). In conclusion, in patients with symptomatic chronic HF, physical inactivity is associated with higher all-cause and cardiac mortality. Failure to exercise and television screen time are additive in their effects on mortality. Even modest exercise was associated with survival benefit.

Section snippets

Methods

We analyzed data from Heart Failure Adherence and Retention Trial (HART),⁴ which was a multihospital, partially blinded, behavioral efficacy randomized controlled trial, funded by the National Institutes of Health [HL065547]. HART assessed the impact of self-management counseling versus education alone on the primary outcome of death or HF-related hospitalization in patients with symptomatic HF. Details of the trial were reported elsewhere.4, 5 The study enrolled patients from 10 centers in the

Results

Physical activity data were available for all 902 subjects (100%) enrolled in HART. The median exercise time in the entire cohort was 60 min/week (interquartile range 7.5 to 143 min/week). A total of 196 patients (22%) were classified as inactive (0 min/week) and 706 (78%) were classified as active (≥1 min/week). The median exercise time among active patients was 90 min/week (interquartile range 36 to 172 min/week). The baseline characteristics of the study groups are summarized in Table 1.

Discussion

These analyses show that physical inactivity in patients with chronic HF was associated with nearly twice the risk of all-cause death and cardiac death. Even modest leisure exercise was associated with significantly reduced risk compared to complete physical inactivity. Moreover, television screen time was associated with incremental risk of all-cause death, above and beyond exercise duration and a broad range of sociodemographic and clinical covariates. Physical activity appears to be

Acknowledgment

The authors thank Guillaume Lambert, PhD, for contribution to the propensity score matching of the study groups.

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Participants (n = 991) were 68 (95 % CI 67–69) years of age, 52.6 (95 % CI 49.0–56.3)% men and had a body mass index of 32.5 (95 % CI 31.8–33.2) kg/m² with follow up time of 68.9 (95 % CI 64.8–72.9) person-months. When models were adjusted for time of eating variables and all other covariates, extending the eating window beyond 11.02 h was associated with decreased risk of cardiovascular (HR 0.36 [95 % CI 0.16–0.81]), but not all-cause mortality. Time of first and last eating occasions were not associated with mortality.
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Heart failure (HF) is a common cause of hospitalization and death, and the hallmark symptoms of HF, including dyspnea, fatigue, and exercise intolerance, contribute to poor patient quality of life (QoL). Cardiac rehabilitation (CR) is a comprehensive disease management program incorporating exercise training, cardiovascular risk factor management, and psychosocial support. CR has been demonstrated to effectively improve patient functional status and QoL among patients with HF. However, CR participation among patients with HF is poor. This review details the mechanisms of dyspnea and exercise intolerance among patients with HF, the physiologic and clinical improvements observed with CR, and the key components of a CR program for patients with HF. Furthermore, unmet needs and future strategies to improve patient participation and engagement in CR for HF are reviewed.
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Citation Excerpt :
Although we found a favorable trend in reduction in mortality risks when ST was substituted with MVPA, such associations were not statistically significant. Our findings are consistent with a growing body of literature demonstrating detrimental effects of ST on health outcomes among patients with HF.9,16 These findings are particularly relevant to the recently published PA guidelines recommending that all populations, including those with conic conditions, should avoid excessive ST and replace it with any type of PA (ie, move more and sit less) to mitigate the health risks associated with ST.1 This evidence, however, is extremely limited in patients with HF.
A sedentary lifestyle is prevalent among patients with heart failure (HF) and is associated with poor prognosis and survival, possibly owing to the displacement of health-enhancing behaviors, such as physical activity (PA). However, there is limited evidence examining the displacement effects of reducing duration of sedentary time (ST) on clinical outcomes in patients with HF. The current study examined the theoretical effects of relocating ST with PA on all-cause and cardiovascular disease (CVD)-specific mortality risks in patients with HF. We analyzed 265 patients with HF who participated in the National Health and Nutrition Examination Survey from 2003 to 2006. Cox proportional hazards regression model was fitted to estimate mortality risks based on objectively measured ST well as time spent in light-intensity PA (LPA) and moderate- and vigorous-intensity PA (MVPA). The theoretical changes in the hazard ratio (HR) by replacing ST with LPA or MVPA were examined using isotemporal substitutional modeling. On average, patients with HF spent 70% of waking hours per day in ST (9.01 hours), followed by LPA (29%; 3.75 hours) and MVPA (1%; 0.13 hours). Ten-minute substitution of ST with LPA was associated with significantly lower all-cause and CVD-specific mortality risks (hazard ratio [HR]=0.93 for both). The mortality risks progressively decreased as more ST was relocated to LPA. The relocation effects of ST with MVPA were not statistically significant, possibly because of limited MVPA accrued in this clinical population. The current study provides empirical evidence about the potential health benefits of replacing a modest amount of ST with LPA among patients with HF.
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Exercise is an important therapeutic intervention in CHF. Also, it has been demonstrated that in patients with CHF, physical inactivity is associated with nearly twice all‐cause and cardiac mortality, and even modest exercise is associated with a survival benefit [24,25]. There is evidence supporting that feedback provided via the telephone and mail by medical staff may be as effective as the more traditional follow-up program in reducing symptoms and improving quality of life [26], and in decreasing rehospitalization rates [27].
The present study analysed the patterns of physical activity pre-, during and post-lockdown measures for COVID-19 pandemic in patients with chronic heart failure (CHF) and cardiac implantable electronic devices (CIED) under remote monitoring (RM), and assessed the physical activity patterns during these periods.
The raw data from 95 patients with CHF (age 67,7 $\pm$ 15,1 years, 71,5% male) corresponding to 2238 RM transmissions of the Medtronic Carelink™ network platform was obtained. The physical exercise profiles and the impact of the lockdown measures on the physical behaviour during and after the measures were analysed. According to the level of activity duration in the pre-lockdown, lockdown and post-lockdown periods, the patterns of behaviour were identified (non-recoverees, incomplete recoverees, recoverees and full-recoverees).
RM of CHF patients with CIED using the Carelink™ network is useful for close follow-up and identification of heart failure risk status variations. After relieving the confinement measures there were two groups of patients that did not recover the previous physical activity levels. Physical inactivity in patients with CHF can have a significant impact on outcomes.
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Cardiac rehabilitation is defined as a multidisciplinary program that includes exercise training, cardiac risk factor modification, psychosocial assessment, and outcomes assessment. Exercise training and other components of cardiac rehabilitation (CR) are safe and beneficial and result in significant improvements in quality of life, functional capacity, exercise performance, and heart failure (HF)–related hospitalizations in patients with HF. Despite outcome benefits, cost-effectiveness, and strong practice guideline recommendations, CR remains underused. Clinicians, health care leaders, and payers should prioritize incorporating CR as part of the standard of care for patients with HF.

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: Funding: The Heart Failure Adherence and Retention Trial (NCT00018005) was funded by the National Heart, Lung, and Blood Institute (HL065547). This study is part of the Rush Center for Urban Health Equity, which is funded by the National Institute for Heart Lung and Blood (NHLBI), grant number 1P50HL105189-01.

: See page 1143 for disclosure information.

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Heart FailureImpact of Physical Inactivity on Mortality in Patients With Heart Failure

Section snippets

Methods

Results

Discussion

Acknowledgment

Am J Prev Med

Am Heart J

J Psychiatr Res

Ann Thorac Surg

J Am Coll Cardiol

J Am Coll Cardiol

JACC Heart Fail

J Am Coll Cardiol

J Am Coll Cardiol

Int J Cardiol

J Am Coll Cardiol

Heart Failure
Impact of Physical Inactivity on Mortality in Patients With Heart Failure