9/12/2016
Exercise and Frailty in
Heart Failure
Teri Diederich, APRN
Objectives
• Define frailty and identify frailty assessment
scores
• Discuss how frailty impacts prognosis in heart
failure
• Identify objective measures of functional
capacity
• Determine exercise programs to impact frailty
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Frailty
No consensus definition in the literature
Most commonly described as a biologic
syndrome of decreased reserve and resistance
to stressors, resulting from cumulative decline
across multiple physiologic systems and
causing vulnerability to adverse outcomes
Frailty Assessment Tools
There are many different tools that have been
created and studied in patients
Tools can be based on
• Rules-based definition
• Counting patient’s clinical deficits
• Measure based on clinical judgement
• Fried Frailty Scale
• Edmonton Frail Scale
• Rockwood’s Frailty Index
• Risk Analysis Index (RAI)
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Fried Frailty Scale
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Measures 5 physical domains
• Shrinking
• Weakness: grip strength
• Poor endurance and energy
• Slowness: time to walk 15 feet
• Physical activity level
> 3/5 is considered frail
Clinically validated in heart failure patients
Edmonton Frail Scale
Measures frailty domains
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Cognition
General health status
Functional
independence
Social support
Medication use
Nutrition
Mood
Continence
Functional
performance
Score
0-5 = Not frail
6-7 = Vulnerable
8-9 = Mild frailty
10-11 = Moderate
frailty
12-17 = Severe frailty
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Rockwood
• Built from clinical frailty
scale
• Measures 70+ deficits
across medical, functional,
and psychosocial domains
• Graded frailty severity for
0.0-1.0
• Clinically burdensome
RAI Score
Measures
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Gender
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Age with/without cancer
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Weight loss in past 3
months
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Renal failure
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Congestive heart failure
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Poor appetite
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Shortness of breath at
rest
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Residence other than
independent living
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Deterioration of cognitive
skills in last 3 months
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Activities of daily living
Gives a score which then
determines a frailty %
Currently studying grip
strength and timed up and
go test as other markers
of frailty
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Why does frailty matter?
Frailty is associated with
• Increased length of hospital stay
• Adverse outcomes post surgery
• Increased mortality
Objective Measures of
functional capacity
6 minute walk test
Timed up and go test
Cardiopulmonary Stress Test
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6 minute walk
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Distance walked in 6 minutes
Allows patient to stop if needed
Also checks heart rate and oxygen capacity
Timed Up and Go Test: A Reliable and Valid
Test in Patients with Chronic Heart Failure
Heart Failure Society of America Guidelines 2010
Journal of Cardiac Failure, 22(8), 646-650, August 2016
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Patient sits in chair
Measures time to stand up, walk 10 feet or 3
meters, turn and walk back and sit back down
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Cardiopulmonary
Stress Test
Gas exchange physiology
Procedure for CPET –
– selection of exercise test protocol
Variables from CPET and their
physiological implications
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Anaerobic (ventilatory) threshold (AT. VT)
Peak Respiratory Exchange Ratio (RER)
V˙ O2max or Peak V˙ O2 and VO2 pulse
Minute Ventilation–Carbon Dioxide Output Relationship
(VE/VCO2)
Why we measure
gas exchange
An important prognostic component of exercise stress
– CO more highly correlated with VO2max than with treadmill time
– VO2max is a more accurate measure of cardiorespiratory fitness
then treadmill time
– Gas exchange provide more information about the health and
performance of the lungs in the case of combined cardiac and
pulmonary disease
Evaluation and quantification of performed work (functional capacity)
– Performed work is measured in MET
• 1 MET is a resting level of O2 consumption/min of a healthy
man weighing 70 kg
• 1 MET = 3.5 mL/kg/min of Vo2
• Simple household activities - 1.5 to 4 METs
• Moderate work/sexual activities 3 to 6 METs
• Heavy work or high-level sports activities 5 to 15 METs
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How is gas exchange
measured?
Close circuit: O2 consumption (VO2) and CO2 output (V CO2) are
equivalent to O2 utilization and CO2 production occurring in the cell :
thus, external respiration equals internal respiration
Metabolic derangements can occur at multiple sites: mitochondria,
muscle, peripheral circulation, heart, pulmonary circulation and lungs
CPET provides knowledge of site and extent of metabolic dysfunction
Cardiopulmonary
Stress Test
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Guidelines for Physical
Activity/Exercise in Heart Failure
Heart Failure Society of America Guidelines 2010
Journal of Cardiac Failure, 16(6), 475-539, June 2010
Exercise Rehabilitation as Therapy for HF
Recommendation
6.19 It is recommended that patients with HF
undergo exercise testing to determine suitability for
exercise training (patient does not develop
significant ischemia or arrhythmias).
♥ Strength of Evidence = B
Evidence arising from cohort studies or smaller clinical trials
Heart Failure Society of America Guidelines 2010
Journal of Cardiac Failure, 16(6), 475-539, June 2010
♥If deemed safe, exercise training should be considered
for patients with HF in order to facilitate understanding of
exercise expectations (heart rate ranges and appropriate
levels of exercise training), to increase exercise duration
and intensity in a supervised setting, and to promote
adherence to a general exercise goal of 30 minutes of
moderate activity/exercise, 5 days per week with warm
up and cool down exercises.
♥ Strength of Evidence = B
Evidence arising from cohort studies or smaller clinical trials
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ACC/AHA Guidelines for the Diagnosis and
Management of Heart Failure in Adults - 2009
Focused Update
Circulation. 2009; 119: 1977-2016
Exercise training is beneficial as an adjunctive
approach to improve clinical status in ambulatory
patients with current or prior symptoms of HF and
reduced LVEF
 Class 1
Recommendation that procedure/treatment is useful/effective
 Level of Evidence B
Data Derived from a single randomized trial or nonrandomized
studies
European Society of Cardiology 2012 Guidelines
(in collaboration with the Heart Failure Association)
European Heart Journal (2012) 33, 1787–1847
♥It is recommended that regular aerobic exercise is
encouraged in patients with heart failure to improve
functional capacity and symptoms.
♥ Recommendation = Class 1
Is recommended/is indicated
♥ Level of Evidence = A
Data derived from multiple randomized clinical trials or metaanalyses
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European Association of Cardiovascular
Prevention and Rehabilitation 2012
Vanhees L 2012. Eur J Prev Cardiol (E-pub)
♥PA recommendations and exercise training programs for
patients with coronary artery disease or chronic heart failure
need to be tailored to the individual's exercise capacity and risk
profile, with the aim to reach and maintain the individually
highest fitness level possible and to perform endurance
exercise training 30-60 min daily (3-5 days per week) in
combination with resistance training
2-3 times a week.
Summary of
recommendations
♥ACC/AHA – Adjunctive therapy – no specifics
♥HFSA - General exercise goal of 30 minutes of
moderate activity/exercise, 5 days per week with
warm up and cool down exercises
♥ESC – Regular aerobic exercise
♥EACPR – Tailored - perform endurance exercise
training 30-60 min daily (3-5 days per week) in
combination with resistance training 2-3 times a
week
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Effect of Exercise Training
in systolic heart failure
♥HFrEF - most studies in systolic dysfunction
♥Benefits ♥
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♥
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Mortality
Morbidity
Quality of Life
Physiological Markers
Neurohumoral Cardiac
Vascular
Skeletal muscle
Metabolic Ventilatory
Cardiac Rehabilitation
• Recommended for all heart failure patients
with reduced ejection fraction, < 35%
• Patients not hospitalized in the last 6 weeks
• Reimbursed by insurance including medicare
and medicaid
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Summary
• Frailty can be helpful in assessing heart failure
patients and should be discussed with patient
• Assessing functional capacity with validated
measures is necessary
• All heart failure patients should participate in
regular exercise programs
Questions?
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