Exercise and Heart Failure Tami Ward MS APRN

Exercise and Heart Failure Tami Ward MS, APRN, NP-C, CHFN October 10, 2013

I have no conflict of interest

�Discuss reduced ejection fraction(HFr. EF) and preserved ejection fraction (HFp. EF) heart failure �Examine the role and recommendations of exercise training in heart failure (HF) �Identify barriers and strategies to overcome these barriers in the HF population Objectives

� The definition of HF has now expanded to: a. HF with reduced ejection fraction � (HFr. EF, EF≤ 40%) b. HF failure with preserved ejection fraction (HFp. EF EF ≥ 50%) c. HFp. EF, borderline (EF 41 -49%) d. HFp. EF, improved (EF >40%) Two Types of HF

Definition of Heart Failure Classification Ejection Fraction Description I. Heart Failure with ≤ 40% Reduced Ejection Fraction (HFr. EF) Also referred to as systolic HF. Randomized clinical trials have mainly enrolled patients with HFr. EF and it is only in these patients that efficacious therapies have been demonstrated to date. II. Heart Failure with Preserved Ejection Fraction (HFp. EF) ≥ 50% Also referred to as diastolic HF. Several different criteria have been used to further define HFp. EF. The diagnosis of HFp. EF is challenging because it is largely one of excluding other potential noncardiac causes of symptoms suggestive of HF. To date, efficacious therapies have not been identified. a. HFp. EF, Borderline 41% to 49% These patients fall into a borderline or intermediate group. Their characteristics, treatment patterns, and outcomes appear similar to those of patient with HFp. EF. b. HFp. EF, Improved >40% It has been recognized that a subset of patients with HFp. EF previously had HFr. EF. These patients with improvement or recovery in EF may be clinically distinct from those with persistently preserved or reduced EF. Further research is needed to better characterize these patients. ACCF/AHA 2013 HF Guidelines JAC 2013 5 June (E-Pub online )

� The number of patients with HF, as well as the cost to treat patients with HF, is expected to increase in the future. � All causes of HF must be evaluated, with consideration of multigenerational family histories and genetic testing. � Risk factors need to be continually addressed when managing a patient with HF: hypertension, lipid disorders, obesity, diabetes mellitus, tobacco use, and known cardiotoxic agents. � There is a clear mortality benefit from using guideline- directed medical therapy. Important points regarding HF management

� Anticoagulation should not be used in patients with chronic HFr. EF with no risk factors (atrial fibrillation, thromboembolic event, or cardioembolic source). � Aim for control of systolic and diastolic blood pressures, as well as volume status, to treat HFp. EF. � Re-evaluate patients with left ventricular EF ≤ 35%, New York Heart Association class II-IV, left bundle branch block, and a QRS ≥ 150 ms for cardiac resynchronization therapy. � HF education, dietary restrictions, and exercise training should be provided for all patients to enhance self-care. � A HF multidisciplinary team, including a palliative care team, should be involved when treating patients with advanced HF. Important points regarding HF management

Classification of Heart Failure A B C ACCF/AHA Stages of HF At high risk for HF but without structural heart disease or symptoms of HF. Structural heart disease but without signs or symptoms of HF. Structural heart disease with prior or current symptoms of HF. None I I II IV D Refractory HF requiring specialized interventions. NYHA Functional Classification No limitation of physical activity. Ordinary physical activity does not cause symptoms of HF. Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in symptoms of HF. Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes symptoms of HF. Unable to carry on any physical activity without symptoms of HF, or symptoms of HF at rest. ACCF/AHA 2013 HF Guidelines JAC 2013 5 June (E-Pub online)

ACCF/AHA 2013 HF Guidelines JAC 2013 5 June (E-Pub online)

�Exercise intolerance due to fatigue and dyspnea most prominent �Other S & S: ◦ Paroxysmal nocturnal dyspnea ◦ Orthopnea, ◦ Edema ◦ Worsening dyspnea with exertion or at rest ◦ Tachycardia ◦ Change in weight Signs and Symptoms in HF patients

� Current Guidelines 2013: ◦ Class I �Exercise training (or regular physical activity) is recommended as safe and effective for patients with HF who are able to participate to improve functional status (Level of Evidence: A) ◦ Class IIa �Cardiac rehabilitation can be useful in clinically stable patients with HF to improve functional capacity, exercise duration, HRQOL, and mortality. (Level of Evidence: B) Role of Exercise Training in HF

�Improvement in exercise capacity after exercise training due to peripheral adaptations (increased oxygen extraction) �Improvement in quality of life �Reduced hospitalizations and mortality �Improved endothelial function �Reduction in catecholamine levels Benefits with exercise and cardiac rehabilitation

�Three major risk factors: age, presence of heart disease and intensity of exercise ◦ Lowest incidence: walking, cycling and treadmill walking ◦ Least active patients are higher risk ◦ In HF patients, most common events include: post-exercise hypotension, atrial and ventricular arrhythmias and worsening HF symptoms Risks to exercise

�Weight gain > 3 lb in 1 -3 days �Drop in systolic BP with exercise (marked/symptomatic) �NYHA IV (can exercise selective patients) �Complex ventricular arrhythmias �Resting heart rate ≥ 100 bpm �Pre-existing unstable co-morbidities Relative Contraindications to Exercise in Stable HF Patients

�Progressive worsening of exercise intolerance (dyspnea at rest) �Ischemia is suspected �Severe AS or severe regurgitant valvular disease �Acute systemic illness �New onset afib �Acute pericarditis/myocarditis/embolism Absolute Contraindications to Exercise with Stable HF Patients

�Aerobic activity such as walking or cycling �Frequency – 3 -5 days a week or most days �Intensity – 55 -80% heart rate reserve with perceived exertion (1114) �Duration of each session – start at 5 minutes if needed and progress to 30 -60 minutes Exercise Recommendations

�Cycling ◦ Allows low level workloads ◦ Easily reproducible ◦ May be safer with orthopedic or balance problems �Walking �Swimming �yoga �Interval training �Flexibility and resistance training Exercise Recommendations

�Patient related �Social and economic �Healthcare team/system �Condition and Therapy related Barriers and possible solutions

�Older age �Low level of education �Low socio-economic status �Minority status �Anxiety and depression �Logistical problems �Lack of motivation, lack of insight into benefits and lack of time Patient related Barriers European Journal of Heart Failure (2012) 14, 451 -458

�Lack or resources and support �Lack of reimbursement �Transportation concerns Social and Economic Barriers European Journal of Heart Failure (2012) 14, 451 -458

�Lack of expertise with heart failure �Lack of capacity �Lack of referral �Lack of education on the importance of exercise Healthcare team/system barriers European Journal of Heart Failure (2012) 14, 451 -458

�Severity of symptoms �Level of disability �Rate of disease progression �Impact of co-morbidities Condition and Therapy Related Barriers European Journal of Heart Failure (2012) 14, 451 -458

�Patient related ◦ Optimize heart failure management; manage co -morbid conditions ◦ Discuss activity at each visit to rehab ◦ Assess preferred mode of exercise ◦ Education; engage patient as partner in exercise ◦ Screen for depression Recommendations to overcome barriers

�System and therapy related ◦ Have referral system in place ◦ Educate providers Recommendations to overcome barriers

� 74 year-old male with history of coronary artery disease; inferior STEMI 2010 (unsuccessful PCI)complicated with cardiogenic shock and VT; initial EF 25%; received single chamber ICD ◦ ◦ ◦ Hypertension Hyperlipidemia Osteoarthritis Ischemic cardiomyopathy insomnia Case study

�Social History ◦ Never used tobacco products ◦ No alcohol and substance abuse ◦ Retired lawyer �Family History ◦ Father died of sudden death – age 60 �Surgical History ◦ Cataracts; ICD implant Case Study

�Medications ◦ Aspirin 81 mg daily ◦ Carvedilol 12. 5 mg twice daily ◦ Lisinopril 20 mg daily (now on study drug – NEP inhibitor) ◦ Furosemide 40 mg twice daily ◦ Potassium 20 m. Eq daily ◦ Simvastatin 40 mg daily ◦ Meloxicam as needed ◦ Trazadone 25 mg at bedtime ◦ Nitroglycerine 0. 4 mg as needed Case study

Case Study �Exercise history ◦ Swimmer in high school ◦ Lifeguard at the Officers Club Pool in the Army Medical Core ◦ Cardiac rehab after STEMI ◦ Resumed swimming after MI �U. S. Master’s �Senior Olympics

9 Gold medals in Kansas Senior Meet September ‘ 13

“My Doctor said if I hadn’t been in such good physical shape from swimming it very likely would have been a fatal heart attack. Swimming or any kind of exercise saves lives”.

�Find strategies to get patients referred and enrolled in your cardiac rehabilitation program �Use this opportunity to give disease specific education to the HF patients �Prescribing exercise for HF patients is similar to patients without HF �Partner with your providers to help keep these patients out of the hospital with close surveillance of their symptoms. In Summary

�Thank You! Tamra. Ward@Alegent. org