1. Patients with acute heart failure who were more frail at baseline derived greater benefits from a tailored, multimodal rehabilitation program than those who were pre-frail.
2. Physical rehabilitation was found to globally improve metrics of physical function and quality of life overall.
Level of Evidence Rating: 1 (Excellent)
Study Rundown: Frailty is a clinical syndrome characterized by a decline in physiologic reserve with decreased ability to respond to stressors. It is common among older adults, especially those with other comorbidities. The Rehabilitation Therapy in Older Acute Heart Failure Patients (REHAB-HF) trial sought to evaluate the impact of a multimodal, individualized physical rehabilitation intervention on the physical function and quality of life of older adult patients with heart failure. The present study is a secondary analysis of this trial, seeking to specifically determine the associated changes in frailty over time as well as changes in adverse event risk.
349 patients were included between 2014 and 2019, of whom 12 were not frail (3.5%), 145 were pre-frail (41.5%), and 192 individuals were frail (55.0%). 292 patients completed the intervention and had outcome data available at 3 months. The mean number of rehabilitation sessions that frail patients attended was 22.3 and 23.6 amongst pre-frail patients. Amongst the baseline frail group, 35% of control patients and 12% of the intervention group experienced a substantial decline in physical function at 3 months; this difference was statistically significant, favouring the intervention group, demonstrating that the intervention is effective in lowering the risk of physical decline over time. The effect size for improvement in physical functioning at 3 months amongst patients who derived benefit from the intervention was 2.6-fold greater amongst the baseline frail patients than those who were pre-frail.
This secondary analysis of the REHAB-HF trial demonstrated that most patients benefited from a tailored physical rehabilitation program over a 12-week period and that individuals who were more frail at baseline tended to derive a greater magnitude of benefit than those who were pre-frail. This work is important in informing patient selection for rehabilitation programming. Strengths of this study include the large size and randomized nature of the trial, which does well to control for confounding. A limitation of this work is the inability to assess meaningful clinical outcomes due to inadequate statistical power, as well as the rigid definition of frailty which may reduce the external validity of these findings. Future research should seek to identify how this program can be best delivered to benefit the most number of vulnerable patients
In-Depth [randomized controlled trial – secondary analysis]: This study represents a predetermined secondary analysis of the REHAB-HF trial. The trial was 12 weeks in duration, giving older adults (age 60 or older) who had been hospitalized with acute heart failure an individualized physical rehabilitation plan and assessing outcomes of physical functioning up to 6 months later. The Fried phenotype was used to define levels of frailty at baseline and at follow-up. The primary outcome was the Short Performance Primary Battery (SPPB) score at 3 months – a global score evaluating performance in gait, balance and strength.
The majority (55.0%) of patients included in this trial were frail at baseline, meeting 3 or more of the Fried criteria. These patients were more likely to have physical and mental health comorbidities than pre-frail patients, although there was no significant difference in heart failure severity amongst the frailty groups. Patients in the control group who were frail at baseline were significantly more likely to experience worsening physical decline as measured by SPPB score at 3 months than those who received the intervention (35% vs 12%; p = 0.002). Amongst pre-frail patients, 17% of those in the intervention group and 19% of those in the control group experienced a decline in SPPB score at 3 months.
Amongst the participants who benefited from the intervention, the effect size was significantly larger amongst patients who were frail at baseline. The overall effect size amongst frail patients in terms of increase in SPPB at 3 months was 2.1 points (95% confidence interval 1.3-2.9) and was 0.8 (-0.1 to 1.6) amongst pre-frail patients. As a percentage increase, the SPPB score improved by 77% (56-98%) amongst baseline frail patients following the intervention and only 18% (-1 to 38%) amongst the frail controls.
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