The HEART Camp Exercise Intervention Improves Exercise Adherence, Physical Function, and Patient-Reported Outcomes in Adults With Preserved Ejection Fraction Heart Failure.

BACKGROUND: Despite exercise being one of few strategies to improve outcomes for individuals with heart failure with preserved ejection fraction (HFpEF), exercise clinical trials in HFpEF are plagued by poor interventional adherence. Over the last 2 decades, our research team has developed, tested, and refined Heart failure Exercise And Resistance Training (HEART) Camp, a multicomponent behavioral intervention to promote adherence to exercise in HF. We evaluated the effects of this intervention designed to promote adherence to exercise in HF focusing on subgroups of participants with HFpEF and heart failure with reduced ejection fraction (HFrEF). METHODS AND RESULTS: This randomized controlled trial included 204 adults with stable, chronic HF. Of those enrolled, 59 had HFpEF and 145 had HFrEF. We tested adherence to exercise (defined as ≥120 minutes of moderate-intensity [40%-80% of heart rate reserve] exercise per week validated with a heart rate monitor) at 6, 12, and 18 months. We also tested intervention effects on symptoms (Patient-Reported Outcomes Measurement Information System-29 and dyspnea-fatigue index), HF-related health status (Kansas City Cardiomyopathy Questionnaire), and physical function (6-minute walk test). Participants with HFpEF (n = 59) were a mean of 64.6 ± 9.3 years old, 54% male, and 46% non-White with a mean ejection fraction of 55 ± 6%. Participants with HFpEF in the HEART Camp intervention group had significantly greater adherence compared with enhanced usual care at both 12 (43% vs 14%, phi = 0.32, medium effect) and 18 months (56% vs 0%, phi = 0.67, large effect). HEART Camp significantly improved walking distance on the 6-minute walk test (η2 = 0.13, large effect) and the Kansas City Cardiomyopathy Questionnaire overall (η2 = 0.09, medium effect), clinical summary (η2 = 0.16, large effect), and total symptom (η2 = 0.14, large effect) scores. In the HFrEF subgroup, only patient-reported anxiety improved significantly in the intervention group. CONCLUSIONS: A multicomponent, behavioral intervention is associated with improvements in long-term adherence to exercise, physical function, and patient-reported outcomes in adults with HFpEF and anxiety in HFrEF. Our results provide a strong rationale for a large HFpEF clinical trial to validate these findings and examine interventional mechanisms and delivery modes that may further promote adherence and improve clinical outcomes in this population. CLINICAL TRIAL REGISTRATION: URL: https://clinicaltrials.gov/. Unique identifier: NCT01658670.

Study of adherence to exercise in heart failure: the HEART camp trial protocol.

BACKGROUND: Adherence to the Heart Failure Society of America (HFSA) 2010 guidelines recommending 30 minutes of supervised moderate intensity exercise five days per week is difficult for patients with heart failure (HF). Innovative programs are needed to assist HF patients to adhere to long-term exercise. The objective of this prospective randomized two-group repeated measures experimental design is to determine the efficacy of a behavioral exercise training intervention on long-term adherence to exercise at 18 months in patients with heart failure. METHODS/DESIGN: A sample size of 246 subjects with heart failure will be recruited over a 3 year period. All subjects receive a cardiopulmonary exercise test and 9 supervised exercise training sessions during a 3 week run-in period prior to randomization. Subjects completing at least 6 of 9 training sessions are randomized to the HEART Camp Intervention group (HC) or to a standard care (SC) exercise group. The HC intervention group receives cognitive-behavioral strategies that address the intervention components of knowledge, attitudes, self-efficacy, behavioral self-management skills and social support. The SC group is provided access to the exercise facility and regular facility staff for the 18 month study period. The primary aim is to evaluate the effect of HEART Camp on adherence to exercise, with our central hypothesis that the HC group will have significantly better adherence to exercise at 18 months. Secondary aims include evaluating which components of the HEART Camp intervention mediate the effects of the intervention on adherence; evaluating the effect of HEART Camp on specific health outcomes; exploring selected demographic variables (race, gender, age) as potential moderators of the effect of the HEART Camp intervention on adherence; and exploring the perceptions and experiences that contextualize exercise adherence. DISCUSSION: The HEART Camp intervention is the first to test a multi-component intervention designed to improve long-term adherence to exercise behavior in patients with HF. Improving long-term adherence to exercise is the logical first step to ensure the required dose of exercise that is necessary to realize beneficial health outcomes and reduce costs in this burdensome chronic illness. TRIAL REGISTRATION: Clincaltrials.gov NCT01658670.

Psychological responses and adherence to exercise in heart failure.

PURPOSE: The purpose of this study was to describe psychological effects and exercise adherence during a multicomponent exercise training intervention. METHODS: A sample of 42 patients with heart failure were randomized into an exercise (INV) group (n = 22) and an attention control (AC) group (n = 20). The exercise protocol included two 12-week phases, a structured phase and a self-managed phase. The psychological responses assessed were mood states and exercise self-efficacy. To meet the second purpose of the study, the exercise group was dichotomized based on the number of sessions completed to create two adherence subgroups. FINDINGS: Results indicate self-efficacy improved for the INV group and was maintained during the self-management phase. The adherence subgroups demonstrated different patterns for weekly exercise. Depression and confusion scores improved for the high-adherence group in contrast to worsening for the low-adherence group. CONCLUSIONS: Results suggest a need for further study of the psychological responses of exercise adherence for patients with heart failure. CLINICAL RELEVANCE: The study indicates the importance of continuous assessment of exercise participation and longer term adherence support for patients with heart failure.

Consistency of the counting talk test for exercise prescription.

The purpose of this study was to assess the consistency of the counting talk test (CTT) method for estimating exercise intensity across various modes of exercise in healthy young adults. Thirty-six individuals completed the study, which required participation in 3 separate sessions within a 2-week time period. During the first session, the individuals completed a maximal effort treadmill test from which each individual's heart rate reserve (HRR) was calculated. During the second and third sessions, the subjects participated in 2 modes of exercise in each session for a total of 4 different modes of exercise. The individuals exercised at 40% HRR, 50% HRR, 60% HRR, 75% HRR, and 85% HRR. The heart rate (HR), CTT, and rating of perceived exertion (RPE) were recorded at each workload. Based on the individual's resting CTT (CTT(rest)), the %CTT for each exercise stage was then calculated. Pearson correlations demonstrated moderate to good correlations between the CTT and HRR methods and the CTT and RPE methods for estimating exercise intensity. This study found that for the individuals with CTT(rest) <25, moderate to vigorous intensity exercise as recommended by the American College of Sports Medicine HRR guidelines could be achieved by exercising at a level of 40-50% CTT(rest). Individuals with a CTT(rest) ≥25, exercising at a level of 30-40% CTT(rest) would place them in the moderate to vigorous exercise intensity range. A high degree of reliability was demonstrated using the CTT method across the various modes of aerobic exercise. As such, independent of the exercise mode, the CTT was found to be an easy and consistent method for prescribing moderate to vigorous aerobic exercise intensity.

A self-directed adherence management program for patients with heart failure completing combined aerobic and resistance exercise training.

This study measured the impact of the Exercise Adherence Management Program (EAMP) provided to 20 patients with heart failure (HF) who participated in a combined resistance and aerobic exercise training program during two 12-week phases. The EAMP included strategies designed to support exercise self-efficacy and adherence. Results indicate that an improvement in exercise self-efficacy occurred during the study period, whereas exercise adherence declined during the unsupervised phase. The highest rated adherence strategy for helpfulness and self-efficacy was group sessions. The study supports the use of adherence strategies based on self-efficacy in exercise programs for patients with HF.

Predicting maximal oxygen uptake from the 6 min walk test in patients with heart failure.

AIMS: A cardiopulmonary exercise (CPX) test is considered the gold standard in evaluating maximal oxygen uptake. This study aimed to evaluate the predictive validity of equations provided by Burr et al., Ross et al., Adedoyin et al., and Cahalin et al. in predicting peak VO2 from 6 min walk test (6MWT) distance in patients with heart failure (HF). METHODS AND RESULTS: New York Heart Association Class I-III HF patients performed a maximal effort CPX test and two 6MWTs. Correlations between CPX VO2 peak and the predicted VO2 peak , coefficient of determination (R2 ), and mean absolute percentage error (MAPE) scores were calculated. P-values were set at 0.05. A total of 106 participants aged 62.5 ± 11.5 years completed the tests. The mean VO2 peak from CPX testing was 16.4 ± 3.9 mL/kg/min, and the mean 6MWT distance was 419.2 ± 93.0 m. The predicted mean VO2 peak (mL/kg/min) by Burr et al., Ross et al., Adedoyin et al., and Cahalin et al. was 22.8 ± 8.8, 14.6 ± 2.1, 8.30 ± 1.4, and 16.6 ± 2.8. A significant correlation was observed between the CPX test VO2 peak and predicted values. The mean difference (0.1 mL/kg/min), R2 (0.97), and MAPE (0.14) values suggest that the Cahalin et al. equation provided the best predictive validity. CONCLUSIONS: The equation provided by Cahalin et al. is simple and has a strong predictive validity, and researchers may use the equation to predict mean VO2 peak in patients with HF. Based on our observation, equations to predict individual maximal oxygen uptake should be used cautiously.

The influence of the HEART Camp intervention on physical function, health-related quality of life, depression, anxiety and fatigue in patients with heart failure.

BACKGROUND: Regular exercise training has beneficial effects on quality of life, physical function, depression and anxiety in individuals with heart failure. Unfortunately, individuals with heart failure have low levels of adherence to exercise. Thus, studies are needed to assess intervention strategies which may enhance clinical outcomes. AIM: The aim of this study was to identify the components of the HEART Camp intervention, which contributed to optimizing clinical outcomes. METHODS: The Heart Failure Exercise and Resistance Training Camp (HEART Camp) was a randomized controlled trial to evaluate the effect of a multicomponent intervention on adherence to exercise (6, 12 and 18 months) compared to an enhanced usual care group. This study assessed various components of the intervention on the secondary outcomes of physical function, health-related quality of life, depression, anxiety, and fatigue. RESULTS: Individuals participating (n=204) in this study were 55.4% men and the average age was 60.4 (11.5) years. A combination of individualized and group-based strategies demonstrated clinical improvements, HEART Camp versus enhanced usual care groups, in physical function, positive trends in health-related quality of life and positive changes in the minimally important differences for depression, anxiety, and fatigue. CONCLUSIONS: Individualized coaching by an exercise professional and group-based educational sessions were identified as important components of patient management contributing to improvements in the secondary outcomes of physical function, health-related quality of life, depression, anxiety and fatigue.

MOVE-HF: an internet-based pilot study to improve adherence to exercise in patients with heart failure.

AIM: The use of the internet and newer activity monitors such as the Fitbit Charge HR to improve exercise adherence is limited. The primary aim of the Move on Virtual Engagement (MOVE-HF) was to investigate the effects of group social support by internet-based synchronized face-to-face video and objective physical activity feedback on adherence to recommended exercise guidelines. METHODS: Thirty stable heart failure patients (New York Heart Association class I-III), aged 64.7±11.5 years, were randomly assigned to an experimental or comparison group. Participants were provided a handout on self-care in heart failure, an exercise routine, a Fitbit Charge HR and were asked to wear the Fitbit Charge HR daily, and record their exercise sessions using both the Fitbit Charge HR and exercise diaries. In addition, participants in the experimental group connected to Vidyo software, once a week, for 8 weeks, for a 45-minute face-to-face online group discussion/education session. RESULTS: Overall Vidyo session attendance was 68%, with 73% of participants attending five or more sessions. Adherence to exercise was 58.8% in the experimental group and 57.3% in the comparison group. The experimental group perceived receiving social support through the internet-based synchronized face-to-face video meetings but due to a small sample size and lack of adequate power, no significant impact on exercise adherence was observed. Participants commented that feedback regarding physical activity from the Fitbit Charge HR was helpful and motivational. CONCLUSION: Delivering social support by internet-based synchronized face-to-face video is feasible with heart failure patients. However, more investigations are needed to understand its impact on exercise adherence.

Feasibility of using the Fitbit® Charge HR in validating self-reported exercise diaries in a community setting in patients with heart failure.

BACKGROUND: Use of wrist-worn activity monitors has increased over the past few years; however, the use of the Fitbit® Charge HR (FCHR) in a community setting in patients with heart failure has not been tested. PURPOSE: The purpose of the study was to assess the feasibility, practicality and acceptability of utilizing the FCHR to validate self-reported exercise diaries and monitor exercise in community dwelling patients with heart failure. METHODS: Thirty heart failure patients (12 females and 18 males) aged 64.7 ± 11.5 years were provided with a FCHR. Participants were provided with an exercise routine and for eight weeks, recorded their exercise sessions in self-reported exercise diaries and used the FCHR to record those exercise sessions. RESULTS: Exercise data from the self-reported exercise diaries were validated with data from the FCHR. Participants' perception and acceptance of using the FCHR was positive. Validation of exercise and physical activity interventions using the FCHR appears feasible and acceptable in patients with heart failure. CONCLUSION: Wrist-worn activity monitors can be useful for objective measurement of exercise adherence and monitoring of physical activity in patients with heart failure in a community setting.

A Home-Based Diaphragmatic Breathing Retraining in Rural Patients With Heart Failure.

Dyspnea limits physical activity and functional status in heart failure patients. This feasibility study examined effects of a diaphragmatic breathing retraining (DBR) intervention delivered over 8 weeks with follow-up at 5 months. The intervention group (n = 18) was trained at baseline and received four telephone calls. An attention control group (n = 18) received four telephone calls with general health information. Results from linear mixed model analysis with effect sizes (η(2)) showed dyspnea improved in both groups, with little difference between groups. Compared with attention alone, the intervention increased physical activity (calories expended; η(2) = .015) and functional status (η(2) = .013) across the 5-month follow-up and increased activity counts at 8 weeks (η(2) = .070). This intervention was feasible and demonstrated promising effects on activity and function but not by reducing dyspnea. Patients may have increased physical activity because of instructions to use DBR during activities of daily living. Further exploration of the intervention's underlying physiological effect is needed.

Reducing cardiovascular risk in spouses of cardiac patients: a randomized controlled trial.

Few studies have examined risk-reducing interventions in spouses of coronary artery bypass patients. This study examined the effects of the Partners Together in Health (PaTH) intervention versus usual care on cardiovascular risk factors. Spouses in the experimental group (n = 17/group) attended cardiac rehabilitation with patients and made the same physical activity and healthy eating changes as patients. Spouses in the usual care group attended educational classes with patients. Spouses' 30-year cardiovascular risk was calculated using the Lifetime Risk Scale before and after cardiac rehabilitation (3 months), and at 6 months. Spouses in both groups significantly reduced 30-year risk scores at 3 and 6 months. Exercise was the key ingredient in lowering risk. There was a trend toward reduction in systolic blood pressure and an increase in high-density lipoprotein cholesterol in both groups. Although there were no group differences, having spouses participate in cardiac rehabilitation with the patient was effective for reducing spouses' cardiovascular risk.

Physical demands of vacuuming in women using different models of vacuum cleaners.

PURPOSE: Women continue to have the primary responsibility for housekeeping, even after a cardiac event. Vacuuming is one housekeeping task that is often reported as difficult to perform due to angina symptoms. The aim of this study was to evaluate the energy expenditure and hemodynamic responses associated with vacuuming using five different models of vacuum cleaners. METHODS: Thirty-six healthy women 50-59 yr of age (54.5 +/- 3.1 yr) participated in this study. Energy expenditure was measured by indirect calorimetry using an Aerosport KB1-C portable metabolic system. After collection of baseline HR, blood pressure (BP), and oxygen consumption ( VO2 ) data, subjects performed vacuuming and treadmill walking in one of six different sequences. Vacuuming consisted of using five different models of vacuum cleaners, three upright models (heavy-duty, self-propelled, and lightweight) and two canister models (standard and compact) for 6 min each. Treadmill walking was conducted at 2.0 mph (0% grade) for 6 min. VO2, HR, BP, and RPE were recorded during each task. The rate-pressure product (RPP) was calculated to estimate myocardial oxygen demand. RESULTS: Vacuuming with the self-propelled upright model resulted in significantly lower VO2, RPE, HR, systolic BP, and RPP responses compared with some of the other models.(2) CONCLUSION: Significant differences in oxygen consumption and myocardial oxygen demand are associated with vacuuming using different models of vacuum cleaners. When making recommendations to individuals regarding the least physiologically demanding models, the power assist features of the machine should be the greatest consideration. This important characteristic should be taken into account when making recommendations for patients with limited capacity, or those wanting to limit physiological stress due to a disease state.

ExPAAC proceedings: Exercise training for individuals with heart failure.

Heart failure (HF) is considered a condition primarily associated with the older population, with approximately 80% of individuals admitted to the hospital with a diagnosis of HF being over the age of 65 years. With the 'aging of the population' in the United States the incidence of HF is expected to continue to rise. Therefore many of the older individuals seen by physical therapists for an array of conditions will have HF as a primary diagnosis or comorbidity which needs to be addressed in developing their plan of care. Current evidence supports the safety and efficacy of exercise training as a component in the overall medical management of individuals with stable HF regardless of age. The primary aims of this article are to review the benefits associated with exercise training in individuals with HF and present the current recommendations for aerobic, resistance and inspiratory muscle exercise training along with recommendations for monitoring and modifying exercise training programs. Clinically, exercise training has been shown to have a significant effect on improving functional capacity, oxygen consumption, 6-minute walk test distances, symptoms, self-efficacy for exercise, and quality of life of individuals with HF. It is important that physical therapists adequately challenge individuals with HF with appropriate exercise intensities, while closely monitoring their patients, in order to achieve optimal functional benefits and quality of life.

Effects of Exercise Training versus Attention on Plasma B-type Natriuretic Peptide, 6-Minute Walk Test and Quality of Life in Individuals with Heart Failure.

PURPOSE: The purpose of this study was to compare an Exercise Training Group (EX) with an Attention-Control Group (AT-C) to more specifically assess the impact of exercise training on individuals with heart failure (HF). METHODS: Forty-two individuals with HF were randomized to AT-C or EX that met with the same frequency and format of investigator interaction. Baseline, 12- and 24-week measurements of B-type naturetic peptide (BNP), 6-minute walk test (6-MWT), and the Kansas City Cardiomyopathy Questionnaire (KCCQ) were obtained. RESULTS: BNP tended to increase in the AT-C while remaining stable in the EX over time. A clinically significant increase in 6-MWT was demonstrated by the EX but not the AT-C. The EX achieved a clinically significant change on the KCCQ at 12 weeks, with further improvement by 24 weeks, while the AT-C demonstrated a clinically significant change at 24 weeks. CONCLUSIONS: Attention alone was inadequate to positively impact BNP levels or 6-MWT distances, but did have a positive impact on quality of life after 24 weeks. Although exercise offers enhanced benefits, individuals with HF unable to participate in an exercise program may still gain quality of life benefits from participation in a peer-support group that discusses topics pertinent to HF.

Heart Failure Exercise And Training Camp: effects of a multicomponent exercise training intervention in patients with heart failure.

BACKGROUND: This study tested the effects of a multicomponent exercise training intervention called "Heart Failure Exercise And Training Camp" (HEART CAMP). The intervention was theoretically derived from Bandura's social cognitive theory. METHODS: An experimental repeated-measures design was used. Participants were randomized to the HEART CAMP intervention group (n = 22) or the attention control group (n = 20). Participants were compared on self-efficacy for exercise, symptoms, physical function, and quality of life over 12 weeks. RESULTS: The intervention group had a 31% increase in cardiac exercise self-efficacy and significantly fewer symptoms compared with the attention control group. Quality of life increased significantly in both groups. CONCLUSION: A theory-based intervention improved self-efficacy for exercise and symptoms in patients with heart failure.

Relationship of resting B-type natriuretic peptide level to cardiac work and total physical work capacity in heart failure patients.

PURPOSE: Plasma B-type natriuretic peptide (BNP) levels obtained at rest have been previously shown to be correlated with the global functional capacity measures of peak oxygen uptake (V(O(2peak))) and the minute ventilation/carbon dioxide (VE/V(O(2))) slope. The purpose of this study was to assess the relationship of the plasma BNP level to the rate-pressure product (RPP) as an indicator of central or cardiac work capacity. METHODS: Twenty-two subjects (12 men), mean age 57 +/- 12 years, diagnosed with heart failure (8 ischemic/14 nonischemic) were recruited. All subjects were stable on optimal medical therapy for at least 1 month. Blood samples for BNP level analysis were obtained at rest. Subjects underwent a symptom-limited treadmill exercise test using a ramping protocol while V(O(2)), heart rate (HR), and blood pressure (BP) were monitored. Correlation analyses were conducted to assess the relationship of BNP level to RPP level, V(O(2peak), VE/V(O(2)) slope, end-tidal CO(2) pressure (P(ET)CO(2)), and left ventricular ejection fraction (LVEF). RESULTS: Resting BNP levels were significantly correlated with RPP levels (r = -0.69). The BNP level and the RPP level were correlated with V(O(2peak)) (r = -0.63 and r = 0.66, respectively) and VE/V(O(2)) slope (r = 0.53 and r = -0.54, respectively). The RPP level but not the BNP level was correlated with P(ET)CO(2) (r = 0.57). Neither BNP nor RPP levels were well correlated with LVEF (r = -0.26 and r = 0.14, respectively). DISCUSSION: The results of this study suggest that resting plasma BNP level may be a useful clinical measure for evaluating both global functional capacity and myocardial specific work capacity in individuals with heart failure.

Validity of the counting talk test in comparison with standard methods of estimating exercise intensity in young healthy adults.

PURPOSE: The Talk Test is a method for recommending exercise intensity on the basis of the ability of an individual to carry on a conversation during exercise and has been associated with defining the upper recommended limits of exercise intensity for cardiorespiratory training. The purpose of this study was to assess the validity of a novel variation of the Talk Test method, the "Counting Talk Test" (CTT), as a semiquantitative approach for estimating exercise intensity in healthy individuals. METHODS: Forty young adults (22.5 +/- 2.3 years) participated in 2 maximal treadmill tests on separate days. The first test was performed to determine maximum heart rate (HR) and oxygen uptake (VO2) and to allow participants to habituate to the testing protocol. During the second session, participants were instructed in the CTT method. HR, rating of perceived exertion (RPE), blood pressure, and CTT were recorded at rest and at each test stage. Correlation analyses were conducted among the variables. RESULTS: Correlation coefficients values, r = -0.93, -0.92, and -0.86, were found between the %CTT and percentage of heart rate reserve (%HRR), percentage of VO2-reserve (%VO2R), and RPE, respectively. CONCLUSIONS: The CTT has concurrent validity with the criterion measure of VO2R as well as to the more commonly utilized measures of HRR and RPE for estimating relative exercise intensity in young adults. Exercising at a level at which individuals could count to half to one third of their resting CTT value corresponded with American College of Sports Medicine's recommendations for moderate to vigorous exercise intensity.

Comparison of the energy expenditure index and oxygen consumption index during self-paced walking in children with spastic diplegia cerebral palsy and children without physical disabilities.

The aim of this study was to assess whether the Energy Expenditure Index (EEI), based on heart rate (HR) adjusted for speed, was a clinical indicator of the Oxygen Consumption Index (OCI), oxygen consumption (VO(2)) adjusted for speed, during self-paced walking in children with spastic diplegia cerebral palsy (CP) and children without physical disabilities (ND). Ten children with spastic diplegia CP and 15 children who are ND participated. VO(2) and HR were measured at rest and during self-paced ambulation using an AeroSport KB1-C portable metabolic system, and the EEI and OCI were calculated. A fair to good correlation (r = 0.61) between EEI and OCI was found for children with spastic diplegia CP ambulating at self-paced speeds while only a moderate correlation (r = 0.40) was found for children who are ND. The results suggest that the EEI may be a useful clinical indicator of OCI at self-paced ambulation speeds in children with spastic diplegia CP and warrants further investigation.