Questionnaire-based scoring system for screening moderate-to-vigorous physical activity in middle-aged Japanese workers.

OBJECTIVES: Currently available questionnaires have limited ability to measure physical activity (PA) using accelerometers as a gold standard. This study aimed to develop a PA questionnaire for middle-aged Japanese workers and propose a PA scoring system for predicting low moderate-to-vigorous PA (MVPA). METHODS: A total of 428 participants (median age 49 years; 75.8% men) participated in a 7-day PA measurement using an accelerometer and a questionnaire. The association between questionnaire responses and low MVPA (<150 min/wk) was assessed by logistic regression analysis. A score was assigned to each response based on the correlation coefficients of the multivariate model. The ability of the sum score to predict low MVPA was assessed using the area under the receiver operating characteristic curve (AUC). RESULTS: Five questionnaire items were used for measuring PA scores (range: 0-50; higher scores indicated a higher probability of low MVPA). The AUC was 0.741 (95% CI, 0.689-0.792), and the sensitivity and specificity at the optimal cut-off value were 66.7% and 68.2%, respectively. This predictive ability was slightly increased by body mass index (AUC 0.745 [95% CI, 0.693-0.796]; sensitivity 69.9%; specificity 66.9%). These predictive values were greater than those of conventional questionnaires used in health checkups in Japan (P < .05). CONCLUSIONS: This questionnaire-based PA scoring system showed moderate accuracy in predicting low MVPA. It is useful for screening physically inactive workers and promoting PA.

Changes in walking speed 6 months after discharge may be more sensitive to subsequent prognosis than handgrip strength in patients hospitalized for heart failure.

BACKGROUND: Despite the prognostic importance of walking speed (WS) and handgrip strength (HGS) in patients with heart failure (HF), no study has reported the prognostic impact of changes in these parameters. This study aimed to examine the association between changes after discharge and the subsequent prognosis. METHODS: This study included 881 elderly patients hospitalized for HF. WS and HGS were measured at discharge and 6 months after discharge. Based on the presence of slowness (WS <0.98 m/s) or weakness (HGS <30.0 kg for men and < 17.5 kg for women) at both points, patients were divided into four groups (WS: A = -/-, B = -/+, C = +/-, D = +/+; HGS: E = -/-, F = -/+, G = +/-, H = +/+). The study endpoint was a composite of all-cause mortality and HF rehospitalization during the 18 months after 6 months of discharge. The Cox proportional hazards model was used to assess the association between the groups and study outcomes. RESULTS: Stratified by the WS change patterns, groups B and D showed higher risk of the study outcomes than group A [B: hazard ratio 2.34, 95% confidence interval (CI) 1.29-4.28; D: 2.38, 1.67-3.39], whereas group C was not. When stratified by the HGS change in patterns, only group H was associated with a worse prognosis (HR; 1.85, 95%CI; 1.31-2.60). CONCLUSION: Changes in WS were related to HF prognosis, suggesting that changes in WS may be more sensitive to further risk stratification than changes in HGS.

Prognostic impact of nutrition measures in patients with heart failure varies with coexisting physical frailty.

AIMS: Malnutrition is prevalent among patients with heart failure (HF); however, the effects of coexisting malnutrition and frailty on prognosis are unknown. This study examines the impact of malnutrition and frailty on the prognosis of patients with HF. METHODS AND RESULTS: We examined 1617 patients with HF aged 65 years or older (age: 78.6 ± 7.4; 44% female) from a Japanese multicentre prospective cohort study. The nutritional status was evaluated using the Geriatric Nutritional Risk Index (GNRI), Controlling Nutritional Status (CONUT), and Mini Nutritional Assessment Short Form on discharge. Frailty was assessed using the criteria determined in a previous study on patients with HF. The prognostic impact of each nutrition measure on the risk of composite all-cause mortality and cardiac readmissions within 2 years of hospital discharge was assessed using Kaplan-Meier survival curves and Cox proportional hazards model analysis for non-frail and frail groups. Over 2324.2 person-years of follow-up, 88 patients died and 448 patients experienced readmission due to HF. In the non-frail group, poor nutritional status assessed using the GNRI and CONUT was associated with an increased hazard ratio (HR) of composite outcomes in the crude model; however, adjustment for potential confounders diminished the association. In the frail group, all three nutritional indicators were associated with the cumulative incidence of the study outcome (log-rank test, P < 0.05). In multivariate analysis, only the CONUT score was associated with an increased HR even after adjustment for confounders. CONCLUSIONS: The CONUT score predicted a poor prognosis in HF patients with coexisting physical frailty, highlighting the potential clinical benefit of nutritional assessment based on biochemical data for further risk stratification.

Physical Frailty and Use of Guideline-Recommended Drugs in Patients With Heart Failure and Reduced Ejection Fraction.

BACKGROUND Guideline-recommended therapies that improve prognosis remain underused in clinical practice. Physical frailty may lead to underprescription of life-saving therapy. We aimed to investigate the association between physical frailty and the use of evidence-based pharmacological therapy for heart failure with reduced ejection fraction and the impact of this on prognosis. METHODS AND RESULTS The FLAGSHIP (Multicentre Prospective Cohort Study to Develop Frailty-Based Prognostic Criteria for Heart Failure Patients) included patients hospitalized for acute heart failure, and data on physical frailty were collected prospectively. We analyzed 1041 patients with heart failure with reduced ejection fraction (aged 70 years; 73% male) and divided them by physical frailty categories using grip strength, walking speed, Self-Efficacy for Walking-7 score, and Performance Measures for Activities of Daily Living-8 score: categories I (n=371; least frail), II (n=275), III (n=224), and IV (n=171). Overall prescription rates of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, ß-blockers, and mineralocorticoid receptor antagonists were 69.7%, 87.8%, and 51.9%, respectively. The proportion of patients receiving all 3 drugs decreased as physical frailty increased (in category I patients, 40.2%; IV patients, 23.4%; P for trend<0.001). In adjusted analyses, the severity of physical frailty was an independent predictor for nonuse of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (odds ratio [OR], 1.23 [95% CI, 1.05-1.43] per 1 category increase) and ß-blockers (OR, 1.32 [95% CI, 1.06-1.64]), but not mineralocorticoid receptor antagonists (OR, 0.97 [95% CI, 0.84-1.12]). Patients receiving 0 to 1 drug had a higher risk of the composite outcome of all-cause death or heart failure rehospitalization than those treated with 3 drugs in physical frailty categories I and II (hazard ratio [HR], 1.80 [95% CI, 1.08-2.98]) and III and IV (HR, 1.53 [95% CI, 1.01-2.32]) in the multivariate Cox proportional hazard model. CONCLUSIONS Prescription of guideline-recommended therapy decreased as severity of physical frailty increased in heart failure with reduced ejection fraction. Underprescription of guideline-recommended therapy may contribute to the poor prognosis associated with physical frailty.

Prognostic effects of cardiac rehabilitation in heart failure patients classified according to physical frailty: A propensity score-matched analysis of a nationwide prospective cohort study.

Background: Research regarding cardiac rehabilitation (CR) in the prognosis of heart failure (HF) patients and frailty remains lacking. Here, the effects of CR on the 2-year prognosis of HF patients were examined according to their frailty status. Methods: This multicenter prospective cohort study enrolled patients hospitalized for HF. Patients who underwent ≥1 session per 2 weeks of CR within 3 months after discharge were categorized in the CR group. Patients were divided in a non-frailty (≤8 points) and physical frailty group (≥9 points) based on their FLAGSHIP frailty score. The score is based on HF prognosis, with a higher score indicating worsened physical frailty. A propensity score-matched analysis was performed to compare survival rates between the two groups according to their physical frailty status. Endpoints included HF re-hospitalization and all-cause mortality during a 2-year follow-up period. Results: Of 2697 patients included in the analysis, 285 and 95 matched pairs were distributed in the non-frailty and physical frailty groups, respectively, after propensity-score matching. CR was associated with lower incidence of HF rehospitalization in both non-frailty (hazard ratio 0.65; 95% confidence interval 0.44-0.96; p = 0.032) and physical frailty (0.54; 0.32-0.90; p = 0.019) groups. CR was not associated with all-cause mortality in either group (log-rank test, p > 0.05). Conclusion: These findings suggest the effects of CR on reduced HF rehospitalization, regardless of physical frailty status.

Factors Associated With Changes in Objectively Measured Moderate to Vigorous Physical Activity in Patients After Percutaneous Coronary Intervention: A Prospective Cohort Study.

BACKGROUND: This study aimed to clarify factors affecting changes in moderate to vigorous physical activity (MVPA) in patients 1 to 3 months after undergoing percutaneous coronary intervention (PCI). METHODS: In this prospective cohort study, we enrolled patients aged <75 years who underwent PCI. MVPA was objectively measured using an accelerometer at 1 and 3 months after hospital discharge. Factors associated with increased MVPA (≥150 min/wk at 3 mo) were analyzed in participants with MVPA < 150 minutes per week at 1 month. Univariate and multivariate logistic regression analyses were performed to explore variables potentially associated with increasing MVPA, using MVPA ≥ 150 minutes per week at 3 months as the dependent variable. Factors associated with decreased MVPA (<150 min/wk at 3 mo) were also analyzed in participants with MVPA ≥ 150 minutes per week at 1 month. Logistic regression analysis was performed to explore factors of declining MVPA, using MVPA < 150 minutes per week at 3 months as the dependent variable. RESULTS: We analyzed 577 patients (median age 64 y, 13.5% female, and 20.6% acute coronary syndrome). Increased MVPA was significantly associated with participation in outpatient cardiac rehabilitation (odds ratio 3.67; 95% confidence interval, 1.22-11.0), left main trunk stenosis (13.0; 2.49-68.2), diabetes mellitus (0.42; 0.22-0.81), and hemoglobin (1.47, per 1 SD; 1.09-1.97). Decreased MVPA was significantly associated with depression (0.31; 0.14-0.74) and Self-Efficacy for Walking (0.92, per 1 point; 0.86-0.98). CONCLUSIONS: Identifying patient factors associated with changes in MVPA may provide insight into behavioral changes and help with individualized PA promotion.

National survey on the secondary preventive measures for coronary artery disease among interventional cardiologists: a report from the Japanese Association of Cardiovascular Intervention and Therapeutics.

Insights from recent clinical trial testing revascularization strategies have interested interventional cardiologists in optimal medical therapy and secondary prevention modalities. As no large-scale survey has been recently conducted, this report presents the results of a nationwide survey on interventionists' concerns regarding secondary prevention after percutaneous coronary intervention (PCI) and discusses medical support system needs in Japan. A questionnaire to assess the status and challenges of secondary prevention interventions by interventional cardiologists during outpatient visits was supplied to Cardiovascular Interventional Technology (CVIT)-certificated hospitals. This was answered by representative cardiologists of each hospital and comprised three queries: (1) the necessity of outpatient cardiac rehabilitation to promote post-PCI lifestyle guidance; (2) the feasibility of providing lifestyle guidance; and (3) the barriers to lifestyle guidance, during outpatient visits. Questions 1 and 2 were answered using a 5-point Likert scale. Survey responses were received from 391 hospitals (54.9% of 712 CVIT-certificated facilities). For Question 1, 327 hospitals (84.1%) answered "agree", and 386 hospitals (98.7%) answered "agree" or "somewhat agree". For Question 2, 10% of hospitals answered "agree", and "agree" and "somewhat agree" amounted to less than 50%. For Question 3, 83.5% of the facilities answered lack of time as the major reason). The next reasons included an early reverse referral to family doctors after PCI, and a lack of managerial advantage (60% and 40% of the hospitals, respectively). In conclusion, interventionists are concerned about secondary prevention for their patients. The issues clarified in the survey will be important for developing next-generation secondary prevention systems.

Factors associated with postsurgical muscle weakness in patients who undergo thoracic aortic surgery: a retrospective cohort study.

OBJECTIVE: Aortic surgery is often performed in elderly patients, and these patients have a high risk of postsurgical muscle weakness. To reinforce purposeful postsurgical rehabilitation, we aimed to investigate the factors associated with postsurgical muscle weakness in patients who underwent thoracic aortic surgery. METHODS: This retrospective cohort study analyzed data of consecutive patients who underwent elective thoracic aortic surgery with cardiopulmonary bypass, and whose knee extensor isometric muscle strength (KEIS) were measured pre- and postoperatively at University Hospital between January 2012 and December 2018. The primary outcome was percent change in KEIS (% change in KEIS). Multivariate linear regression analysis was used to identify independent risk factors for % change in KEIS. RESULTS: Overall, 218 patients were included. Multivariate linear regression analysis showed that mechanical ventilation time, days from initial sitting to 100 m walking, and the number of exercises in the rehabilitation room were associated with % change in KEIS. CONCLUSIONS: This study may serve as a reference to stratify patients at risk of postsurgical muscle weakness. The preventive or alternative interventions in patients undergoing thoracic aortic surgery will be assessed in future studies.

Neuromuscular electrical stimulation after cardiovascular surgery mitigates muscle weakness in older individuals with diabetes.

BACKGROUND: Cardiovascular surgery leads to postsurgical muscle weakness, probably because of muscle proteolysis and peripheral nerve dysfunction, which are augmented by aging and diabetes mellitus. OBJECTIVE: We examined the effect of neuromuscular electrical stimulation (NMES) on postsurgical muscle weakness in older individuals with diabetes mellitus. METHODS: We conducted a multicentre, randomized, controlled trial, and screened consecutive patients with diabetes who underwent cardiovascular surgery for eligibility (age ≥ 65 years). Those included were randomly assigned to the NMES or the sham group. The primary outcome was the percent change in isometric knee extension strength (%ΔIKES) from preoperative to postoperative day 7. Secondary outcomes were the percent change in usual (%ΔUWS), maximum walking speed (%ΔMWS), and grip strength (%ΔGS). A statistician who was blinded to group allocation used intention-to-treat analysis (student t test). RESULTS: Of 1151 participants screened for eligibility, 180 (NMES, n = 90; sham, n = 90) were included in the primary analysis. %ΔIKES was significantly lower in the NMES than sham group (NMES: mean -2%, 95% confidence interval [CI] -6 to 1; sham: -13%, 95% CI -17 to -9, p < 0.001). Among the secondary outcomes, %ΔMWS was significantly lower and %ΔUWS and %ΔGS were lower, although not significantly, in the NMES than sham group. CONCLUSIONS: A short course of NMES (< 1 week) mitigated postsurgical muscle weakness and functional decline in older persons with diabetes mellitus. NMES could be recommended as a part of postsurgical rehabilitation in older people with diabetes mellitus, especially those with a low functional reserve.

Physical Frailty May Predict 2-Year Prognosis in Elderly Patients With Acute Myocardial Infarction　- A Report From the FLAGSHIP Study.

BACKGROUND: Elderly patients with acute myocardial infarction (AMI) are a high-risk population for heart failure (HF), but the association between physical frailty and worsening prognosis, including HF development, has not been documented extensively.Methods and Results: As part of the FLAGSHIP study, we enrolled 524 patients aged ≥70 years hospitalized for AMI and capable of walking at discharge. Physical frailty was assessed using the FLAGSHIP frailty score. The primary outcome was a composite outcome of all-cause death and HF rehospitalization within 2 years after discharge. The secondary outcome was all-cause death and HF rehospitalization. After adjusting for confounders, physical frailty showed a significant association with an increased risk of the composite outcome (hazard ratio [HR]=2.09, 95% confidence interval [CI]: 1.03-4.22, P=0.040). The risk of HF rehospitalization increased with physical frailty, but the association was not statistically significant (HR=2.14, 95% CI: 0.84-5.44, P=0.110). Physical frailty was not associated with an increased risk of all-cause death (HR=1.45, 95% CI: 0.49-4.26, P=0.501). CONCLUSIONS: The findings suggest that physical frailty assessment serves as a stratifying tool to identify high-risk populations for post-discharge clinical events among ambulant elderly patients with AMI.

Association Between the Redox State of Human Serum Albumin and Exercise Capacity in Patients With Cardiac Disease.

The redox state of human serum albumin (HSA) is reported to be an oxidative stress biomarker; however, its clinical use in cardiac disease has not yet been examined. This study aimed to investigate the relation between the redox state of HSA and exercise capacity, which is a robust prognostic factor, in patients with cardiovascular disease. This cross-sectional study included outpatients with cardiac disease. Exercise capacity was assessed by peak oxygen consumption (peakVO2) measured using symptom-limited cardiopulmonary exercise testing. The high-performance liquid chromatography postcolumn bromocresol green method was used to part HSA into human nonmercaptalbumin (oxidized form) and human mercaptalbumin (HMA, reduced form). The fraction of human mercaptalbumin found in HSA (f[HMA]) was calculated as an indicator of the redox state of HSA. The association between peakVO2 and f(HMA) was examined using the Spearman correlation coefficient and multivariate linear regression analysis. A total of 70 patients were included (median age 76 years; 44 men; median peakVO2 15.5 ml/kg/min). The f(HMA) was positively correlated with peakVO2 (r = 0.38, p <0.01). Even after controlling for potential confounders, this association remained in the multivariate linear regression analysis (standardized beta = 0.24, p <0.05). We found a positive association between f(HMA) and peakVO2, independent of potential confounders in patients with cardiac disease, suggesting that f(HMA) may be a novel biomarker related to exercise capacity in cardiac disease. Longitudinal studies are required to further examine the prognostic capability of f(HMA), the responsiveness to clinical intervention, and the association between f(HMA) and cardiac disease.

Association of Redox State of Human Serum Albumin with Severity in Patients with Heart Failure.

Oxidative stress plays a crucial role in the progression of heart failure (HF). We surveyed the fraction of human mercaptalbumin [f (HMA) ], an indicator of the redox state of human serum albumin (HSA), in patients with HF and examined whether f (HMA) is associated with the severity of HF.We enrolled consecutive elderly patients hospitalized for acute HF or exacerbation of HF. The redox state of HSA was measured by the high-performance liquid chromatography with postcolumn bromocresol green method using serum samples collected close to discharge. First, the distribution of f (HMA) in HF was compared to that in community-dwelling elderly individuals (n = 125; median age, 80 years) as a control group analyzed in a previous study. Overall, 133 patients (median age, 81 years; 75 men) were included. Patients with HF showed a lower level of f (HMA) than those of the control group (55.0% [IQR 47.7-61.3] versus 66.3% [IQR 62.8-70.0], P < 0.001]. Multiple regression analysis showed a negative correlation between f (HMA) and log-transformed B-type natriuretic peptide (standardized beta = -0.19).Patients with HF showed lower f (HMA) than those in the control group. Additionally, f (HMA) was related to HF independently with log-transformed B-type natriuretic peptide in the multivariate regression analysis, suggesting that f (HMA) is a biomarker that reflects the redox state in HF patients.

Cardiopulmonary exercise responses in patients with non-ischemic heart failure and a mildly reduced ejection fraction.

Background: The cardiopulmonary response to exercise in patients with heart failure exhibiting a mildly reduced ejection fraction (41% ≤ EF ≤ 49%) remains unclear. Materials & methods: A total of 193 consecutive patients with heart failure (excluding those with coronary artery disease) who underwent cardiopulmonary exercise (CPX) tests were examined. CPX variables were compared among patients with reduced, mildly reduced, and preserved EF. Results: The CPX test responses of patients with mildly reduced EF were similar to those of patients with reduced or preserved EF; however, increases in systolic blood pressure during exercise differed significantly (32 ± 26, 50 ± 24, and 41 ± 31 mmHg, respectively; p = 0.016). Grip strength and an increase in systolic blood pressure during exercise were independently associated with peak oxygen uptake in patients with mildly reduced EF (ß = 0.41, 0.35, respectively; p < 0.05). Conclusion: Measurements of grip strength and blood pressure during exercise are useful predictors of prognoses in patients with non-ischemic and mildly reduced EF.

Cardiopulmonary exercise (CPX) test is widely used to evaluate the function related to heart in heart failure patients. The heart failure patients are divided into three groups: with reduced wall motion (HFrEF), with mildly reduced wall motion (HFmrEF) and with preserved wall motion (HFpEF). We compared the cardiopulmonary reaction to exercise among the three groups. The CPX test responses of patients with HFmrEF were similar to those of patients with HFrEF or HFpEF. However, increases in systolic blood pressure during exercise differed (32 ± 26, 50 ± 24, and 41 ± 31 mmHg, respectively; p = 0.016). Grip strength and an increase in systolic blood pressure during exercise were independently associated with peak oxygen uptake, which is an important predictor of rate of death in patients with HFmrEF. Measurements of grip strength and blood pressure during exercise are useful predictors of progress in patients with enough blood supply to the heart and HFmrEF.

Clinical benefit of combined assessment of physical and psychological frailty in patients with heart failure.

OBJECTIVES: Physical frailty becomes a robust risk factor in patients with heart failure (HF) and coexistence of physical and psychological frailty is likely to be a prognostic indicator. This study aimed to analyze the prognosis of coexistence of these two factors in patients with HF. METHODS: This study was a secondary analysis of a multicenter prospective cohort study (FLAGSHIP). We analyzed data from 2502 patients with HF from the FLAGSHIP study in Japan. We divided the patients into four physical frailty categories using a frailty score ranging from 0 to 14 (<4: I, 4-8: II, 9-12: III, and 14: IV, the score 13 does not exist in calculation). The higher category indicates more severe physical frailty. Psychological frailty was defined as the presence of cognitive decline and/or depressive symptoms. The study outcome was a 2-year composite outcome of rehospitalization for HF or all-cause mortality after hospital discharge. RESULTS: During the 3734.7 person-year follow-up, 774 patients experienced the composite outcome. After adjusting for confounders, physical and psychological frailty were independently associated with adverse outcomes. Using physical frailty category I, without psychological frailty as the reference, adjusted hazard ratios for adverse outcomes were 1.29 [95% confidence interval (CI) 0.86-1.92] for category I with psychological frailty, 0.99 (95% CI 0.71-1.37) for category II without psychological frailty, 1.61 (95% CI 1.16-2.23) for category II with psychological frailty, 1.56 (95% CI 1.14-2.15) for category III without psychological frailty, 1.62 (95% CI 1.20-2.20) for category III with psychological frailty, 1.50 (95% CI 1.05-2.14) for category IV without psychological frailty, and 2.16 (95% CI 1.59-2.94) for category IV with psychological frailty, respectively. CONCLUSIONS: Combined assessment of physical and psychological frailty leads to more detailed risk stratification of patients with HF.

Relationship between spleen size and exercise tolerance in advanced heart failure patients with a left ventricular assist device.

OBJECTIVE: Spleen volume increases in patients with advanced heart failure (HF) after left ventricular assist device (LVAD) implantation. However, the relationship between spleen volume and exercise tolerance (peak oxygen consumption [VO2]) in these patients remains unknown. In this exploratory study, we enrolled 27 patients with HF using a LVAD (median age: 46 years). Patients underwent blood testing, echocardiography, right heart catheterization, computed tomography (CT), and cardiopulmonary exercise testing. Spleen size was measured using CT volumetry, and the correlations/causal relationships of factors affecting peak VO2 were identified using structural equation modeling. RESULTS: The median spleen volume was 190.0 mL, and peak VO2 was 13.2 mL/kg/min. The factors affecting peak VO2 were peak heart rate (HR; ß = 0.402, P = .015), pulmonary capillary wedge pressure (PCWP; ß = - 0.698, P = .014), right ventricular stroke work index (ß = 0.533, P = .001), blood hemoglobin concentration (ß = 0.359, P = .007), and spleen volume (ß = 0.215, P = .041). Spleen volume correlated with peak HR, PCWP, and hemoglobin concentration, reflecting sympathetic activity, cardiac preload, and oxygen-carrying capacity, respectively, and was thus related to peak VO2. These results suggest an association between spleen volume and exercise tolerance in advanced HF.

Prognostic Effects of Cardiac Rehabilitation in Patients With Heart Failure (from a Multicenter Prospective Cohort Study).

The prognostic effects of cardiac rehabilitation (CR) are inconsistent in recent reports on heart failure (HF). Generally, participants in previous trials were relatively young and had HF with reduced ejection fraction. Herein, we examined the effects of CR on HF prognosis using a nationwide cohort study. This multicenter prospective cohort study included hospitalized patients with acute HF or worsening chronic HF. Patients who underwent CR once or more times weekly for 6 months after discharge were included in the CR group. The main study end point was a composite of all-cause mortality and HF rehospitalization during a 2-year follow-up period. We performed propensity score matching to compare the survival rates between the CR and non-CR groups. Of the 2,876 enrolled patients, 313 underwent CR for 6 months. After propensity score matching using confounding factors, 626 patients (313 pairs) were included in the survival analysis (median age: 74 years). CR was associated with a reduced risk of composite outcomes (hazard ratio [HR] 0.66; 95% confidence interval [CI] 0.48 to 0.91; p = 0.011), all-cause mortality (HR 0.53; 95% CI 0.30 to 0.95; p = 0.032), and HF rehospitalization (HR 0.66; 95% CI 47 to 0.92; p = 0.012). Subgroup analysis showed similar CR effects in patients with HF with preserved ejection fraction (≥50%) and HF with reduced ejection fraction (<40%). In the landmark analysis, CR did not reduce the aforementioned end points beyond 6 months after discharge (log-rank test: composite outcomes, p = 0.943; all-cause mortality, p = 0.258; HF rehospitalization, p = 0.831). CR is a standard treatment for HF regardless of HF type; however, further challenges may affect the long-term prognostic effects of CR.