Ya’ll know how much I love freeing the yoke! Chronic disease is a huge burden to the general population. This post is the first in a series of posts addressing some of the major chronic diseases placing a yoke around the necks of our patients. We will discuss what these diseases are, what causes them, and what we can do about it! I’ll help you with what you need to know before you go. Let’s talk about one of the major culprits: Heart Failure.
In 2012-2013, new terminology was adopted for the description of heart failure types. Even though it is not widely used, the new language has increased awareness of and research on diastolic dysfunction and opened our eyes to the two major types of heart failure. We used to just think “left” or “right” or “both”, and that wasn’t exactly wrong, but heart failure is more complicated than that, so the terminology needed to be a better descriptor of what was actually going on.
Heart Failure reduced Ejection Fraction (HFrEF)
Also classically known as systolic heart failure, Heart Failure with Reduced Ejection Fraction indicated that the patient has an Ejection Fraction of <40%. In patients with this diagnosis, EKG abnormalities are more common, indicating that heart rhythm issues are present. HFrEF is clearly associated with coronary heart disease (CHD). HFrEF is typically caused by:
- Myocardial Infarction
- Viral myocarditis
- Physical damage to the heart tissue
Damage to the actual cardiac muscle, electrical, valvular, or vascular tissue is what reduces the ejection fraction in these patients. Either the pump can’t pump as hard (left ventricle), the electrical function is interrupted which results in incoordination and decreased strength of contraction (left ventricle), the valve can’t close and open properly so blood slips out when it isn’t supposed to, or the coronary vasculature can’t supply the oxygen and nutrients to the musculature that it requires. In some of the more long-term causes, blood pools up in the left ventricle, stretching the muscle beyond it’s optimal length and reduces the strength of contraction.
This heart failure is typically more of sudden onset which can result in patients having increased difficulty coping and managing the symptoms. Thankfully, because it typically has a sudden onset, the heart musculature doesn’t have enough time to atrophy before rehab professionals are able to intervene. So, although the patients with this type of heart failure may struggle emotionally or mentally with their new diagnosis, their physical function is less limited after initial diagnosis. This is, of course, dependent on the degree of infarction or physical damage.
There are some in the category who do have significant physical damage or require longer term treatment, such as with viral infections. They may be significantly debilitated due to PICS. Sometimes, this condition is caused by long term disease which results in a larger level of damage, especially if the diseases are left uncontrolled for a longer period of time. Causes of this kind of damage can include:
- Hypertension
- Coronary Artery Disease (CAD)
- Mitral Regurgitation
- Aortic Stenosis
This is a great population for us to jump in with. These are the folks that are still feeling pretty ok. They know they are going to be facing difficulties, but they typically are ready to go on the rehab to prevent HFrEF from affecting them for as long as possible. They can also undergo procedures to correct for some of these issues (like TAVR procedures for valve repairs). But for hypertension and CAD, prevention is key. One of my patients with HFrEF diagnosis had to be discharged early from home care services because he had reached his only self-selected goal which was to go kayaking with his grandsons. All the warm and fuzzies. We still transitioned him to outpatient cardiac rehab for long term management, though.
Heart Failure preserved Ejection Fraction (HFpEF)
In Heart Failure with preserved Ejection Fraction, the left ventricle of the heart cannot properly fill with blood. Overall, less blood than “normal” still leaves the heart, but 55% or more of the blood in the left ventricle still leaves the chamber. Therefore, the ejection fraction is maintained, but the cardiac output is still less. The ventricle can still pump well but the ventricle walls may be very stiff, so cannot relax enough to fill properly during diastole. This can also happen is the heart wall muscle becomes too thick and the chamber no longer holds as much blood. HFpEF can be diagnosed if the ejection fraction is anything greater than 40%. HFpEF is more likely in females and renal failure a more common comorbidity. Causes include:
- Long term hypertension
- Complication of uncontrolled diabetes or long term diabetes (severely stiffened arteries systemically including coronary arteries)
- Failure/Sarcopenia due to debility and/or obesity
- Hypertrophic Cardiomyopathy
- Aortic Stenosis
- Pericardial Disease (abnormalities of the sac surrounding the heart)
As you can see, many of the causes are the same as HFrEF. That is because the development of these conditions depends on the systemic condition of the person, comorbidities, overall physical level, and many other factors. However, the difference here is that HFpEF is typically caused by long term chronic diseases, which means that I’ve seen a lot of these patients.
The difficulty with treating HFpEF is that these patients ride the long slow train down the very slight decline. There can definitely be a triggering event that starts the train ride, but it is all down hill. The burden of chronic disease takes its toll on their body and the recovery process involves riding that long slow train back up the hill. This takes a lot of time and a lot of effort on the part of the patient and the therapist. The other hard piece to the puzzle is that we don’t usually get to intervene here until much later in the disease process which means there has been systemic muscle atrophy, multiple system failure, and ongoing difficulty with chronic disease management. These patients require a good deal of monitoring at all times when participating in activity because they tend to have a very low overall tolerance.
The medication burden to the patient with HFpEF is also much higher and more difficult to sustain. They are typically treated with mineralocorticoid receptor antagonists (spironolactone or eplerenone) which cause hyperkalemia, as well as other medications that elevate potassium, so potassium level and intake must be monitored regularly. Have you ever heard of Milrinone? Nasty business… And then add in that they may also require hemodialysis three days per week due to the associated renal failure, and the physical, mental, and emotional toll of that… I have tons of research on that but we will address ESRD in another post.
This all means that, as the physical therapist, exercise may not be the best or only intervention you are providing. This also means that you have some serious considerations for whole-patient management that go far beyond your assessments and interventions. Let’s talk about some of those things…
The treatment is still exercise!
Regardless of the type of heart failure, the treatment is the same: MOVE! Where you start is definitely going to differ based on acuity and type. More acute HFrEF may need phase 1 cardiac rehab interventions, but may progress to stage 3 quickly and be on their merry way. However, patient with HFpEF will be in phase 2 for a very long time and may meander across stages and settings of care. They typically endure a relapsing/remitting disease course that places a large burden on themselves and their caregivers. Baseline functional assessments and outcome measures are critical for patients with HFpEF because progress is long and labored so maintaining skilled care can be more difficult.
Straight from the Clinical Practice Guideline, here is the exercise prescription patients with heart failure need. Please observe those RPE levels… that’s right… 90-95% peak workload is your target.
| Physical therapists must prescribe aerobic exercise training for patients with stable, NYHA Class II-III HFrEF using the following parameters: Time: 20–60 min; Intensity: 50%–90% of peak VO2 or peak work; Frequency: 3–5/wk; Duration: at least 8–12 wks; Mode: treadmill or cycle ergometer or dancing (Evidence Quality I; Recommendation Strength: A—Strong) | |
| Physical therapists should prescribe high-intensity interval exercise training in selected patients for patients with stable, NYHA Class II-III HFrEF using the following parameters: Time: >35 min; Intensity: >90%–95% of peak VO2 or peak work; Frequency: 2–3/wk; Duration: at least 8–12 wks; Mode: treadmill or cycle ergometer. HIIT total weekly exercise doses should be at least 460 kcal, 114 mins, or 5.4 MET-hrs. (Evidence Quality I; Recommendation Strength: A—Strong) |
There is also plenty of information on the strengthening of the muscles of respiration using IMT training and proper prescription of resistance training. Dr. Shoemaker and his crew even provide the guidance for combining all the different types of training so you can get it all in. We will get in to more details of High-Intensity Interval Training in another post. I’m super excited about that!
Other than exercise…
Keep in mind all the things we talked about in the post about the Rule of 2s! All of these things still come in to play for every one of these patients. Many patients with HFrEF don’t receive the education on how to manage their heart failure using the Rule of 2 because they tend to go quickly in and out of treatment, but that doesn’t mean they don’t need it! If they want to get back to their normal life and live it the best they can for as long as possible, they need to manage themselves properly to prevent decompensation and be healthy enough to participate in exercise or activity-based interventions.
Yes, that means you need to take your patient’s weight. You need to check their weight log. You need to listen to their lungs at every visit and know what you are listening for. You need to check their heart rate (manually, because they have rhythm issues, remember?), blood pressure, and pulse oximetry before, during, and after activity. And if you are in the outpatient setting, you definitely need to do this. Just because someone walked in to your clinic today doesn’t mean they are healthy. That 72-year-old man here for a basic knee evaluation may have knee pain from joint effusion resulting from lower extremity edema secondary to fluid overload. I’ve seen it. This is chronic disease management. Within our scope, within our ability = our responsibility.
For more specifics on treating patients with heart failure, please take a read on the BRAND SPANKING NEW Clinical Practice Guideline for Physical Therapists Managing Heart Failure!
What baseline functional outcome measure is your “go-to” for patients with heart failure? Tell me in the comments!
References:
Black, H. R. & Pitt, B. (2015). HFpEF: The ‘New’ Heart Failure. Commentary for MedScape. Retrieved from http://www.medscape.com/viewarticle /838790#vp_3
Ho, J. E., Gona, P., Pencina, M. J., Tu, J. V., Austin, P. C., Vasan, R. S., Kannel, W. B., D’Agostino, R. B., Lee, D. S., Levy, D. (2012). Discriminating clinical features of heart failure with preserved vs. reduced ejection fraction in the community. European Heart Journal. 33(14):1734–1741. https://doi.org/10.1093/eurheartj/ehs070
Oktay, A. A., Rich, J. D., & Shah, S. J. (2013). The emerging epidemic of heart failure with preserved ejection fraction. Current heart failure reports, 10(4), 401–410. https://doi.org/10.1007/s11897-013-0155-7
Pai, R. K., Thompson, E. G., Gabica, M. J., Husney, A. (2019). Heart Failure With Reduced Ejection Fraction (Systolic Heart Failure). HealthWise. Retrieved from https://www.uwhealth.org/health/topic/special/heart-failure-withreduced-ejection-fraction-systolic-heartfailure/tx4090abc.html#:~:text=Heart%20failure%20with%20reduced%20ejection%20fraction%20happens%20when%20the%20muscle,less%20than%20the%20body%20needs.
Pai, R. K., Thompson, E. G., Gabica, M. J., Husney, A. (2019). Heart Failure With Reduced Ejection Fraction (Systolic Heart Failure). HealthWise. Retrieved from https://www.uofmhealth.org/health-library/tx4091abc
Shoemaker, M. J., Dias, K. J., Lefebvre, K. M., Heick, J. D., & Collins, S. M. (2020). Physical Therapist Clinical Practice Guideline for the Management of Individuals With Heart Failure. Physical therapy, 100(1), 14–43. https://doi.org/10.1093/ptj/pzz127
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Doctor B (the PT) 
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