Updated Guidelines on Heart Failure

Recently the American College of Cardiology, the American Heart Association, and the Heart Failure Society of America updated their Guideline for the Management of Heart Failure. Like the 2013 guideline, the new guideline recommends that people who have some symptoms of heart failure (Stage C) participate in cardiac rehab.

Specifically the two recommendations are as follows:

• For patients with heart failure who are able to participate, exercise training (or regular physical activity) is recommended to improve functional status, exercise performance, and quality of life and

• In patients with heart failure, a cardiac rehabilitation program can be useful to improve functional capacity, exercise tolerance, and health-related quality of life.

The guideline’s authors found high levels of evidence for the significant benefits of cardiac rehab.

Unfortunately, too many people who are referred to cardiac rehab do not go for a number of reasons, one of which is that they cannot get access to a rehab facility. But the Increasing Access to Quality Cardiac Rehabilitation Care Act would expand and expedite access to cardiac rehabilitation. With a few easy steps, you can take ask your members of Congress to increase access to cardiac rehabilitation programs!

The guideline also notes the unfortunate racial and ethnic disparities in mortality and hospitalization for heart failure which are a reminder of AHA’s valuable work towards achieving health equity for all.

Class of Recommendation and Level of Evidence

The Class of Recommendation (COR) indicates the strength of recommendation, encompassing the estimated magnitude and certainty of benefit in proportion to risk.

The Level of Evidence (LOE) rates the quality of scientific evidence supporting the intervention on the basis of the type, quantity, and consistency of data from clinical trials and other sources (Table 2).

7.1.3. Management of Stage C HF: Activity, Exercise Prescription, and Cardiac Rehabilitation

Recommendations for Management of Stage C HF: Activity, Exercise

COR LOE Recommendations

1 A

1. For patients with HF who are able to participate, exercise training (or regular physical activity) is recommended to improve functional status, exercise performance, and QOL.^1–9

2a B-NR

1. In patients with HF, a cardiac rehabilitation program can be useful to improve functional capacity, exercise tolerance, and health-related QOL.^1,2,5,6,8

From the 2013 ACCF/AHA Guideline for the Management of Heart Failure

7.3.1.6. Activity, Exercise Prescription, and Cardiac Rehabilitation: Recommendations

Class I

1. 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 (404-407). (Level of Evidence: A)

Class IIa

1. Cardiac rehabilitation can be useful in clinically stable patients with HF to improve functional capacity, exercise duration, HRQOL, and mortality (404, 406-411). (Level of Evidence: B)

The AHA and ACC

Increasing Access to Quality Cardiac Rehabilitation Care Act of 2021

The legislation would expand and expedite access to cardiac and pulmonary rehabilitation services by authorizing physician assistants, nurse practitioners, and clinical nurse specialists to order CR and PR under Medicare and begin supervising this care in 2022 rather than 2024 as currently allowed.

SOS: Sustaining Outpatient Services Act

This bill will allow new/re location/expansion of hospital outpatient CR programs at any on or off campus location without the Medicare payment reduction.

This was a result of Section 603 of the Bipartisan Budget Act of 2015, so legislation is necessary to correct this “unintended consequence” for CR services.

Programs are fiscally unable to open satellite/rural programs or to move from on campus to larger off campus facilities, which would provide the opportunity to offer more accessibility closer to where beneficiaries live, to reduce hospital discharge to CR enrollment delays, to decrease capacity limitations that contribute to excessive wait times and non-adherence.

Synopsis

Exercise training in patients with HF is safe and has numerous benefits. In a major trial of exercise and HF, exercise training was associated with a reduction in CVD mortality or hospitalizations in the exercise training group after adjustment for risk factors.¹ Meta-analyses show that cardiac rehabilitation improves functional capacity, exercise duration, and health-related QOL. A cardiac rehabilitation program for patients with HF usually includes a medical evaluation, education regarding the importance of medical adherence, dietary recommendations, psychosocial support, and an exercise training and physical activity counseling program. Patients with HF on optimal GDMT, who are in stable medical condition and are able to participate in an exercise program, are candidates for an exercise rehabilitation program.^10,11  

“Cardiac rehabilitation” is not mentioned in the 2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure.