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EDITORIAL
Exercise: integral part in the multidisciplinary approach to heart failure management?
:Lolden MeueWvM
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eart failure (HF) is a major health problem with a large socioeconomic burden of chronic disease, dependency and readmissions to hospital. Patients frequently suffer from symptoms as breathlessness, fatigue and
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oedema. Reduced exercise capacity and disability in different activities result in physical and psychosocial limitations affecting the quality of life of patients and their environment.
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It is generally agreed that a multidisciplinary approach to treatment and is needed to achieve optimal patient outcomes, such as in healthcare utilisation and associated costs, quality of life and mortality.12 Several (inter)national multidisciplinary guidelines on diagnosis and treatment of HF have been published in recent years and the European guidelines on diagnosis and treatment of HF will be updated this year. Optimal diagnosis and medical treatment according to the most recent evidence are of great importance to improve the condition and survival of HF patients. In addition, nonpharmacological interventions are stressed. These nonpharmacological interventions include: Intense education and counselling (inpatient and outpatient, home-based); Iifestyie changes (e.g. regarding diet, alcohol restriction, smoking cessation); Discharge planning; care
-
-
-
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-
-
Vigilant follow-up;
Attention to behavioural strategies; Addressing barriers to compliance; Early attention to signs and symptoms (e.g. dailyweighing, telemonitoring); Flexible diuretic regimen; Increased access to healthcare providers; Exercise programme.
Although basic agreement can be achieved on the content of care needed by HF patients (e.g. all patients should be properly counselled), the organisation of the care often depends on local resources, availability and enthusiasm of local healthcare providers. It is still not established what the optimal dose and contact form (e.g. telephone contact, clinic visit or home visit) is for these patients. At this moment several studies (DEAL and COACH) are in progress that will give more insight into cost-effectiveness of HF management programmes in the Netherlands.34 However, independent of the organisation of care, the importance of including physical training of HF patients in multidisciplinary management becomes clearer. Traditionally, patients with HF were instructed not to exercise in order to avoid deterioration. Heart failure was described as a contraindication for exercise training. More recently, several studies have demonstrated that training programmes in selected HEF patients are feasible and safe and that physical training can induce favourable clinical effects.5 Exercise training programmes are encouraged in stable patients in NYHA class II-III.
Netherlans Heart Journal, Volume 12, Number 6, June 2004
259
Editorial
It will probably take some time and energy to convince healthcare providers, patients and their families of the potential benefits and safety of physical exercise for HF patients. Due to symptoms, HF patients are often not able to perform certain normal daily activities or have to decrease the rate at which they carry out these tasks. Even when patients report few symptoms during normal activities, their maximal exercise capacity is almost always reduced.6 It often seems more obvious to protect these patients from exercise. However, if physical training is directed at training the major muscle groups used in daily life, daily function of HF patients can be improved and it this may be of great impact on their quality oflife.7
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Patients who are seen at the HF clinic often have been deconditioned from, for example, prolonged bed rest or repeated hospitalisations. Others have been inactive because of fear of increasing symptoms or fear of exertion. These patients can possibly benefit most from exercise programmes, either in a cardiac rehabilitation centre or in a hospital-based or home exercise programme. In practice, the physical therapist, exercise physiologist and rehabilitation physician are not always routinely involved in programmes provided in heart failure clinics. There is often not enough knowledge and expertise to prescribe a beneficial exercise programme. Until now specific recommendations regarding exercise programmes, such as the type, duration and intensity of exercise, were scarce. The recently published statements on cardiac rehabilitation from the Committee on Cardiac Rehabilitation of the Netherlands Society of Cardiology and of the Netherlands Heart Foundation and the elaboration published in this issue by Senden, Mosterd and Brugemann are very valuable for promoting acceptance that heart failure is no longer an absolute contraindication for physical training.8 For practical reasons it might not be feasible to enrol every heart failure patient in a cardiac rehabilitation programme. However, advising the patient regarding reconditioning, training and also practical advice on energy conservation should be considered as an essential component of multidisciplinary management of HF patients. A vague advice to patients to 'balance their daily activities' is no longer acceptable. At the same time it should be recognised that in order to establish cardiac rehabilitation exercise programmes as a routine option in HF, as is the case after myocardial infarction, well-powered randomised controlled trials are needed, also in other HF patient groups, for example the elderly, women, and patients in NYHA IV. i T. Jaarsma, D.J. van Veldbuisen, Department of Cardiology, Academic Medical Hospital, Groningen
.....
References 1 Multidisciplinaire richtlijn Chronisch hartfalen. Nederlandse Vereniging voor Cardiologie en Nederlandse Hartstichting. Alphen aan den Rijn: Uitgeverij Van Zuiden B.V., 2002. 2 McAlister FA, Lawson FM, Teo KK, Armnstrong PW. A systematic review ofrandomized trials of disease management programs in heart failure. AmJMed 2001;110:378-84. 3 Jaarsma T, Veldhuisen DJ van. Research set-up concerning the effectiveness of heart failure clinics in the Netherlands. Ned Tijdschr Geneeskd 2003;147:513-4. 4 Jaarsma T, Wal MH van der, Hogenhuis J, Lesman I, Luttik ML, Veeger NJ, et al. Design and methodology of the COACH study: a multicenter randomised Coordinating study evaluating Outcomes ofAdvising and Counselling in Heart failure. EurJHeartFail 2004;6: 5 6 7 8
260
227-33. Piepoli MF, Capucci A. Exercise Training in Heart Failure: Effect on Morbidity and Mortality. IntJCardioI2000;73:3-6. Liang C, Stewart DK, LeKemtie, et al. Characteristics of peak aerobic capacity in symptomatic and asymptomatic subjects with left ventricular dysfunction. AmjCardiol 1992;69:1207-11. Tyni-Lenne R, Dencker K, Gordon A, Jansson E, Sylven C. Comprehensive local muscle training increases aerobic working capacity and quality oflife and decreases neurohormonal activation in patients with chronic heart failure. EurJHeart Fail 2001;3:47-52. Senden PJ, Mosterd A, Brugemann J. Physical training ofpatient with chronic heart failure. Neth HeartJ2004;12:279-86.
Ncthcrlands Heart Journal, Volume 12, Number 6, June 2004
.,
..; ~~~~~.... ... ...;. ...;; ~~ ~ ..
EDITORIAL
Exercise: integral part in the multidisciplinary approach to heart failure management?
:Lolden MeueWvM
A:.;h' m
eart failure (HF) is a major health problem with a large socioeconomic burden of chronic disease, dependency and readmissions to hospital. Patients frequently suffer from symptoms as breathlessness, fatigue and
GWo.....pn!j -n
oedema. Reduced exercise capacity and disability in different activities result in physical and psychosocial limitations affecting the quality of life of patients and their environment.
N..a
.
t Jwrsma v
WE..... .M.
Nhsuwegei. ...:,..,
m R.N.
S
Gmflsn
TIN. .oo,hotifit.
J,H&.' P *-.
_ ''' .er
,....
a,''::.: a n. ,i
It is generally agreed that a multidisciplinary approach to treatment and is needed to achieve optimal patient outcomes, such as in healthcare utilisation and associated costs, quality of life and mortality.12 Several (inter)national multidisciplinary guidelines on diagnosis and treatment of HF have been published in recent years and the European guidelines on diagnosis and treatment of HF will be updated this year. Optimal diagnosis and medical treatment according to the most recent evidence are of great importance to improve the condition and survival of HF patients. In addition, nonpharmacological interventions are stressed. These nonpharmacological interventions include: Intense education and counselling (inpatient and outpatient, home-based); Iifestyie changes (e.g. regarding diet, alcohol restriction, smoking cessation); Discharge planning; care
-
-
-
'0 w ;ossum
-
-
Vigilant follow-up;
Attention to behavioural strategies; Addressing barriers to compliance; Early attention to signs and symptoms (e.g. dailyweighing, telemonitoring); Flexible diuretic regimen; Increased access to healthcare providers; Exercise programme.
Although basic agreement can be achieved on the content of care needed by HF patients (e.g. all patients should be properly counselled), the organisation of the care often depends on local resources, availability and enthusiasm of local healthcare providers. It is still not established what the optimal dose and contact form (e.g. telephone contact, clinic visit or home visit) is for these patients. At this moment several studies (DEAL and COACH) are in progress that will give more insight into cost-effectiveness of HF management programmes in the Netherlands.34 However, independent of the organisation of care, the importance of including physical training of HF patients in multidisciplinary management becomes clearer. Traditionally, patients with HF were instructed not to exercise in order to avoid deterioration. Heart failure was described as a contraindication for exercise training. More recently, several studies have demonstrated that training programmes in selected HEF patients are feasible and safe and that physical training can induce favourable clinical effects.5 Exercise training programmes are encouraged in stable patients in NYHA class II-III.
Netherlans Heart Journal, Volume 12, Number 6, June 2004
259
Editorial
It will probably take some time and energy to convince healthcare providers, patients and their families of the potential benefits and safety of physical exercise for HF patients. Due to symptoms, HF patients are often not able to perform certain normal daily activities or have to decrease the rate at which they carry out these tasks. Even when patients report few symptoms during normal activities, their maximal exercise capacity is almost always reduced.6 It often seems more obvious to protect these patients from exercise. However, if physical training is directed at training the major muscle groups used in daily life, daily function of HF patients can be improved and it this may be of great impact on their quality oflife.7
ibdd Uc,
-.
P0 :.0.03.383 AB £udn,: TheNl*ads::'' ,423'34 22 9900 Fa: +Si-33-422 99 22 E*mAI: in rd eLnI
ISSQ9297456
.-.... . . . . . . . . .4 . mi lw
.e.l
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.S
jourHewt Joume Is' 'oflkl NeUwtw-ds of thie' NeidnS9o"la,Of net C&dolgy.
tboEtoilBor s
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an.. JO until theOfb endfI: .
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i_
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t
::':
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-ioma S.
AlRFlsReserved. No pert, of tubcet1on maybe reprode sWW;:4n rebleval, or transmitted In any form Or.b.yw~te ~~~~~~~~~~~~~~~
medi_stlet DS _ Mal, NededandslitdsworHs
Iojndw~T4IdsohdpwnorH
admersetCmes(nt) n
eupenJora
meedans 1ewtby
le
Patients who are seen at the HF clinic often have been deconditioned from, for example, prolonged bed rest or repeated hospitalisations. Others have been inactive because of fear of increasing symptoms or fear of exertion. These patients can possibly benefit most from exercise programmes, either in a cardiac rehabilitation centre or in a hospital-based or home exercise programme. In practice, the physical therapist, exercise physiologist and rehabilitation physician are not always routinely involved in programmes provided in heart failure clinics. There is often not enough knowledge and expertise to prescribe a beneficial exercise programme. Until now specific recommendations regarding exercise programmes, such as the type, duration and intensity of exercise, were scarce. The recently published statements on cardiac rehabilitation from the Committee on Cardiac Rehabilitation of the Netherlands Society of Cardiology and of the Netherlands Heart Foundation and the elaboration published in this issue by Senden, Mosterd and Brugemann are very valuable for promoting acceptance that heart failure is no longer an absolute contraindication for physical training.8 For practical reasons it might not be feasible to enrol every heart failure patient in a cardiac rehabilitation programme. However, advising the patient regarding reconditioning, training and also practical advice on energy conservation should be considered as an essential component of multidisciplinary management of HF patients. A vague advice to patients to 'balance their daily activities' is no longer acceptable. At the same time it should be recognised that in order to establish cardiac rehabilitation exercise programmes as a routine option in HF, as is the case after myocardial infarction, well-powered randomised controlled trials are needed, also in other HF patient groups, for example the elderly, women, and patients in NYHA IV. i T. Jaarsma, D.J. van Veldbuisen, Department of Cardiology, Academic Medical Hospital, Groningen
.....
References 1 Multidisciplinaire richtlijn Chronisch hartfalen. Nederlandse Vereniging voor Cardiologie en Nederlandse Hartstichting. Alphen aan den Rijn: Uitgeverij Van Zuiden B.V., 2002. 2 McAlister FA, Lawson FM, Teo KK, Armnstrong PW. A systematic review ofrandomized trials of disease management programs in heart failure. AmJMed 2001;110:378-84. 3 Jaarsma T, Veldhuisen DJ van. Research set-up concerning the effectiveness of heart failure clinics in the Netherlands. Ned Tijdschr Geneeskd 2003;147:513-4. 4 Jaarsma T, Wal MH van der, Hogenhuis J, Lesman I, Luttik ML, Veeger NJ, et al. Design and methodology of the COACH study: a multicenter randomised Coordinating study evaluating Outcomes ofAdvising and Counselling in Heart failure. EurJHeartFail 2004;6: 5 6 7 8
260
227-33. Piepoli MF, Capucci A. Exercise Training in Heart Failure: Effect on Morbidity and Mortality. IntJCardioI2000;73:3-6. Liang C, Stewart DK, LeKemtie, et al. Characteristics of peak aerobic capacity in symptomatic and asymptomatic subjects with left ventricular dysfunction. AmjCardiol 1992;69:1207-11. Tyni-Lenne R, Dencker K, Gordon A, Jansson E, Sylven C. Comprehensive local muscle training increases aerobic working capacity and quality oflife and decreases neurohormonal activation in patients with chronic heart failure. EurJHeart Fail 2001;3:47-52. Senden PJ, Mosterd A, Brugemann J. Physical training ofpatient with chronic heart failure. Neth HeartJ2004;12:279-86.
Ncthcrlands Heart Journal, Volume 12, Number 6, June 2004
