Abstract
Background
Prolonged hospital length of stay (LOS) remains a major clinical and economic challenge in heart failure (HF) management. Although early initiation of cardiovascular physical therapy improves functional capacity and prognosis in HF, the impact of delayed initiation on LOS has not been fully clarified. This study examined the association between the timing of cardiovascular physical therapy initiation and prolonged LOS in patients hospitalized for HF.
Methods and Results
This retrospective cohort study included 280 patients hospitalized for HF between January 2022 and December 2023. Patients were categorized into standard and prolonged LOS groups based on the median LOS of 17 days. Receiver operating characteristic curve analysis identified hospital Day 3 as the optimal cut-off for predicting prolonged LOS. Patients who initiated cardiovascular physical therapy on or after Day 3 had a significantly longer LOS than those who started within 2 days (24±14 vs. 19±12 days; P<0.01). Delayed initiation remained independently associated with prolonged LOS after adjustment for age, sex, Meta-Analysis Global Group in Chronic Heart Failure score, intensive care unit stay duration, and B-type natriuretic peptide.
Conclusions
Delayed initiation of cardiovascular physical therapy beyond hospital Day 3 was independently associated with prolonged hospitalization in HF patients. Early initiation guided by hemodynamic assessment during the acute phase may reduce LOS and improve the efficiency of HF care.
Key Words: Cardiovascular physical therapy, Clinical outcomes, Early mobilization, Heart failure, Length of stay
Central Figure.
Heart failure (HF) imposes a substantial burden on healthcare systems worldwide due to its high prevalence and frequent hospital readmissions.1 One of the major challenges in HF management is prolonged hospital length of stay (LOS), which is often driven by factors such as advanced age, multimorbidity, frailty, and malnutrition. Extended hospitalization is associated with an increased risk of in-hospital complications,2,3 as well as higher rates of readmission and mortality.4 Therefore, identifying modifiable determinants of prolonged LOS is essential to optimize resource allocation and improve clinical outcomes in patients with HF.
Cardiovascular physical therapy, which includes early mobilization and structured exercise programs, has been established as an effective intervention for improving functional outcomes5 and reducing hospital readmission rates in patients with HF.6 The 2025 Guidelines for the Diagnosis and Treatment of Heart Failure in Japan7 recommend initiating early mobilization within 48 h of hospitalization to prevent physical deconditioning. Although the benefits of early cardiovascular physical therapy have been well documented, the impact of delayed initiation on hospital LOS remains insufficiently investigated. This study aimed to evaluate the influence of the timing of cardiovascular physical therapy initiation on hospital LOS in patients hospitalized with HF.
Methods
Study Design and Participants
This retrospective single-center study was conducted at Matsushita Memorial Hospital, Japan, between January 2022 and December 2023. Consecutive adult patients (aged ≥18 years) admitted to the Department of Cardiology for the treatment of HF were included. The diagnosis of HF was based on the Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure.8 The following patients were excluded: those who died during hospitalization; were transferred to another hospital for ongoing care; did not receive cardiovascular physical therapy due to clinical contraindications; were discharged at their own request; developed coronavirus disease 2019 (COVID-19) infection during hospitalization; or were transferred to another department during their hospital stay.
Patient Characteristics
Baseline demographic and clinical characteristics were extracted from electronic medical records. Variables included age, sex, body mass index (BMI), and comorbidities such as hypertension, diabetes, atrial fibrillation, and dementia. Additional clinical information included HF exacerbation triggered by infection, prior hospitalization for HF, left ventricular ejection fraction, Clinical Frailty Scale (CFS) score, Barthel Index (BI) at admission, presence of long-term care insurance, and living status (alone or with others). Laboratory parameters at admission included plasma B-type natriuretic peptide (BNP), hemoglobin, serum albumin, and estimated glomerular filtration rate (eGFR). Nutritional status was assessed using the Geriatric Nutritional Risk Index (GNRI), calculated from serum albumin and BMI. The Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score was also calculated to estimate HF severity. Indicators of acute-phase management included intensive care unit (ICU) admission, use of mechanical ventilation, inotropic support, and urinary catheter placement.
Cardiovascular Physical Therapy
Cardiovascular physical therapy was implemented according to the Standard Cardiac Rehabilitation Program for Heart Failure,9 designed to progressively improve functional capacity and cardiovascular health. Each program began with a comprehensive assessment by a licensed physical therapist. Hemodynamic stability was confirmed through evaluation of vital signs, fluid balance, and oxygen saturation before initiating individualized rehabilitation. Cardiovascular physical therapy was initiated as early as possible in the ICU or general ward, depending on clinical stability. Interventions followed a stepwise mobilization protocol – progressing from sitting and standing to ambulation – and were subsequently advanced to aerobic training in the rehabilitation room, including walking or stationary cycling exercises. Exercise intensity was prescribed using a Borg Rating of Perceived Exertion (RPE) scale of 11–13. Sessions were provided for approximately 20–40 min per day for 5 days per week. Throughout rehabilitation, physiological responses to exercise were continuously monitored, with careful attention to hemodynamic fluctuations, subjective fatigue, and signs of HF exacerbation.
Outcome Measures
The primary outcome was hospital LOS. Based on the median LOS of 17 days, patients were classified into standard LOS (<17 days) and prolonged LOS (≥17 days) groups.
The exposure variable was the number of days from hospital admission to the initiation of cardiovascular physical therapy. Receiver operating characteristic (ROC) curve analysis was performed to determine the optimal cut-off point of rehabilitation initiation associated with prolonged LOS. Patients were subsequently categorized into 2 groups according to this threshold for further analyses.
Statistical Analysis
Continuous variables are expressed as mean±standard deviation (SD), and categorical variables are presented as counts and percentages. Between-group comparisons were performed using the chi-square test for categorical variables and Student’s t-test for continuous variables. A 2×2 contingency table was constructed to examine the distribution of early (<3 days) and delayed (≥3 days) initiation of cardiovascular physical therapy across the standard and prolonged LOS groups, and differences were evaluated using the chi-square test. The discriminatory ability of the timing of cardiovascular physical therapy initiation to predict prolonged LOS was evaluated using ROC curve analysis, and the area under the curve (AUC) was calculated to determine the optimal cut-off value. To investigate the association between delayed rehabilitation and prolonged hospitalization, logistic regression analyses were performed. The dependent variable was prolonged LOS, and the main independent variable was delayed rehabilitation initiation (on or after hospital Day 3). Univariable logistic regression was conducted first, followed by multivariable models adjusting for potential confounders. Model 1 was adjusted for age and sex, and Model 2 was further adjusted for MAGGIC score, ICU stay duration and log transformed BNP.
Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each model. Sensitivity analyses were conducted to verify the robustness of the results, including stratified analyses by MAGGIC score, CFS, and GNRI.
No missing data were observed for any variable. All analyses were conducted using EZR (version 4.0.0; Saitama Medical Center, Jichi Medical University, Saitama, Japan), a graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria). A 2-sided P value <0.05 was considered statistically significant.
Results
A total of 342 patients hospitalized for HF were screened, and the following were excluded: in-hospital death (n=22); transfer to another hospital for continued treatment (n=17); no implementation of cardiovascular physical therapy (n=12); discharge at the patient’s request (n=6); development of COVID-19 infection during hospitalization (n=3); and transfer to another department (n=2).
After applying these criteria, 280 patients were included in the final analysis (mean age 79.8±8.7 years; 143 [51%] men). The mean time from hospital admission to the initiation of cardiovascular physical therapy was 2.7±2.5 days, and the mean hospital LOS was 20.1±13.1 days. Among all patients, 121 (43.2%) were classified into the standard LOS group (mean 12.1±2.9 days), and 159 (56.8%) into the prolonged LOS group. ROC curve analysis identified hospital Day 3 as the optimal cut-off for predicting prolonged LOS (sensitivity 74.2%; specificity 44.6%; AUC 0.62; 95% CI 0.56–0.69; P<0.01).
A total of 167 (59.6%) patients initiated cardiovascular physical therapy within the first 2 hospital days, whereas 113 (40.4%) patients started on or after hospital Day 3. Baseline characteristics stratified by early (<3 days) and delayed (≥3 days) initiation are presented in Table 1. Compared with the early initiation group, the delayed group was significantly older, had a higher MAGGIC score, and exhibited lower levels of hemoglobin, albumin, and GNRI. Moreover, delayed initiation was associated with higher rates of long-term care insurance use, indwelling urinary catheterization, and inotropic agent use during the acute phase. In contrast, sex, BMI, comorbidities (hypertension, diabetes, atrial fibrillation), left ventricular ejection fraction, pre-admission BI, and living status did not differ significantly between groups.
Table 1.
Baseline Characteristics According to the Timing of Cardiovascular Physical Therapy Initiation
| All patients (n=280) |
Early initiation (<3 days; n=167) |
Delayed initiation (≥3 days; n=113) |
P value | |
|---|---|---|---|---|
| Age (years) | 80±11 | 78±12 | 82±9 | <0.01 |
| Male | 143 (51) | 91 (55) | 52 (46) | 0.17 |
| Body mass index (kg/m2) | 22±4 | 22±4 | 21±5 | 0.07 |
| Comorbidities | ||||
| Hypertension | 226 (81) | 136 (81) | 90 (80) | 0.71 |
| Diabetes | 106 (38) | 63 (38) | 43 (38) | 0.96 |
| Atrial fibrillation | 91 (33) | 59 (35) | 32 (28) | 0.22 |
| Dementia | 51 (18) | 25 (15) | 26 (23) | 0.10 |
| Cause of exacerbation: infection | 66 (24) | 35 (21) | 31 (27) | 0.22 |
| Prior hospitalization for HF | 135 (48) | 83 (50) | 52 (46) | 0.52 |
| LV ejection fraction (%) | 44±15 | 43±15 | 45±14 | 0.12 |
| Laboratory data at admission | ||||
| BNP (pg/mL) | 781±747 | 736±702 | 847±807 | 0.24 |
| Hemoglobin (g/dL) | 12±2 | 12±2 | 11±2 | <0.01 |
| Albumin (g/dL) | 3.5±0.5 | 3.5±0.5 | 3.4±0.5 | 0.02 |
| eGFR (mL/min/1.73 m2) | 43±22 | 44±20 | 43±24 | 0.98 |
| GNRI | 93±13 | 94±12 | 90±13 | <0.01 |
| MAGGIC score | 29±7 | 28±7 | 30±6 | 0.03 |
| Clinical Frailty Scale at admission | 3.3±1.2 | 3.4±1.2 | 3.1±1.3 | 0.12 |
| Barthel Index at admission | 82±24 | 82±24 | 84±25 | 0.44 |
| Acute phase treatment | ||||
| ICU admission | 47 (17) | 23 (14) | 24 (21) | 0.11 |
| Ventilatory support | 26 (9) | 13 (8) | 13 (12) | 0.31 |
| Inotropes | 23 (8) | 8 (5) | 15 (13) | <0.01 |
| Indwelling urinary catheter | 161 (58) | 80 (48) | 81 (72) | <0.01 |
| Long-term care insurance | 162 (58) | 88 (53) | 74 (66) | 0.03 |
| Living alone | 155 (55) | 96 (58) | 59 (52) | 0.39 |
| Days to rehabilitation start (days) | 2.7±2.5 | 1.4±0.5 | 4.6±3.0 | <0.01 |
Data are presented as mean±SD, or n (%). Early initiation was defined as starting cardiovascular physical therapy within 2 days of admission; delayed initiation was defined as starting on or after hospital Day 3. BNP, B-type natriuretic peptide; eGFR, estimated glomerular filtration rate; GNRI, Geriatric Nutritional Risk Index; HF, heart failure; ICU, intensive care unit; MAGGIC, Meta-Analysis Global Group in Chronic Heart Failure.
Patients who began cardiovascular physical therapy on or after hospital Day 3 had a significantly longer LOS compared with those who started within 2 days (24±14 vs. 19±12 days; P<0.01; Figure). As shown in Table 2, a 2×2 contingency analysis demonstrated that the proportion of patients who began cardiovascular physical therapy on or after hospital Day 3 was significantly higher in the prolonged LOS group than in the standard LOS group (χ2=7.21; P<0.01).
Figure.
Patients who began cardiovascular physical therapy on or after hospital Day 3 had a significantly longer LOS compared with those who started within 2 days (24±14 vs. 19±12 days; P<0.01).
Table 2.
Association Between Hospital LOS and Timing of Cardiovascular Physical Therapy
| Days from admission to rehabilitation initiation | ||
|---|---|---|
| Early initiation (<3 days) |
Delayed initiation (≥3 days) |
|
| LOS | ||
| Standard LOS (<17 days) | 83 | 38 |
| Prolonged LOS (≥17 days) | 84 | 75 |
Data are presented as number of patients. Standard LOS was defined as a hospital stay of <17 days, and prolonged LOS as ≥17 days. Early initiation was defined as starting cardiovascular physical therapy before hospital Day 3, and delayed initiation as starting on or after hospital Day 3. The distribution of patients across these categories differed significantly (P<0.01 by chi-square test). LOS, length of stay.
Results of the logistic regression analysis are summarized in Table 3. In univariable analysis, delayed initiation of cardiovascular physical therapy (≥hospital Day 3) was significantly associated with prolonged LOS (odds ratio 2.32; 95% CI 1.40–3.84; P=0.001). This association remained statistically significant after multivariable adjustment for age, sex, MAGGIC score, ICU stay duration and log transformed BNP (adjusted odds ratio 1.82; 95% CI 1.03–2.97; P=0.03). In sensitivity analyses, consistent trends were observed across strata defined by MAGGIC score and GNRI. After additional adjustment for frailty status (CFS≥4), delayed initiation of cardiovascular physical therapy remained independently associated with prolonged hospitalization (odds ratio 1.69; 95% CI 1.02–2.89; P=0.03).
Table 3.
Univariable and Multivariable Logistic Regression Analyses for the Association Between Delayed Initiation of Cardiovascular Physical Therapy (≥Hospital Day 3) and Prolonged Length of Stay
| Univariate | Model 1 | Model 2 | ||||
|---|---|---|---|---|---|---|
| OR (95% CI) | P value | OR (95% CI) | P value | OR (95% CI) | P value | |
| Delayed initiation ≥Day 3 | 2.32 (1.40–3.84) | 0.001 | 2.07 (1.23–3.49) | 0.006 | 1.82 (1.03–2.97) | 0.03 |
Adjusted models: Model 1 – age and sex; Model 2 – Model 1+MAGGIC score, intensive care unit stay days and log-transformed B-type natriuretic peptide. CI, confidence interval; MAGGIC, Meta-Analysis Global Group in Chronic Heart Failure; OR, odds ratio.
Discussion
In this retrospective study of patients hospitalized for HF, we demonstrated that delayed initiation of cardiovascular physical therapy was associated with prolonged LOS. Among 280 patients analyzed, more than half (56.8%) experienced a hospital stay longer than 17 days, and those with delayed initiation had significantly longer LOS compared with those who started earlier. This association persisted even after adjustment for age, sex, disease severity and ICU stay, indicating that rehabilitation timing itself may represent a modifiable determinant of hospital LOS.
This study demonstrated that delayed initiation of cardiovascular physical therapy was associated with prolonged LOS among patients with HF in Japan. Previous studies examining the relationship between the timing of cardiovascular physical therapy initiation and LOS have been limited,10,11 and its clinical implications have not been fully elucidated. Although numerous studies have investigated LOS in the context of HF,12–15 the definition of ‘prolonged hospitalization’ varies widely across reports, making direct comparison difficult. In the present study, a threshold of 17 hospital days was adopted to define prolonged LOS, corresponding to the transition from Phase II to Phase III in Japan’s Diagnosis Procedure Combination (DPC)-based reimbursement system. Under this system, reimbursement declines as hospitalization extends beyond Phase II, making discharge after Day 17 a key indicator of both clinical and economic efficiency. By quantifying the association between the timing of cardiovascular physical therapy initiation and hospitalization beyond this threshold, our study provides novel evidence that is meaningful from both clinical and health-economic perspectives. While Japan’s DPC framework offers a unique context for defining prolonged LOS, similar economic and clinical pressures exist worldwide, underscoring that timely rehabilitation initiation is a universally relevant issue across healthcare systems.
In this study, initiation of cardiovascular physical therapy on or after hospital Day 3 was identified as the optimal threshold for predicting prolonged hospitalization, and this association remained significant after adjustment for baseline characteristics and HF severity. Notably, the mean time to initiation of cardiovascular physical therapy in this cohort (2.7±2.5 days) was consistent with values reported in recent real-world data on hospitalized patients with HF,16 supporting the clinical validity of this cut-off. The finding that cardiovascular physical therapy initiated within 3 days aligns with the 2025 Japanese guidelines for the diagnosis and treatment of heart failure, which recommend mobilization within 48 h of hospitalization.7 Previous studies have also demonstrated that early initiation of cardiovascular physical therapy contributes to improved functional recovery and better clinical outcomes,17–19 whereas initiation of ambulation after hospital Day 4 has been shown to be independently associated with poorer post-discharge prognosis.6 Therefore, beginning cardiovascular physical therapy within 2 days of admission and achieving ambulation by Day 3 may represent a practical and evidence-based target that facilitates both early recovery and efficient care delivery. While prolonged bed rest leads to muscle atrophy and physical deconditioning,20,21 early involvement of physical therapists allows for the prescription of safe, individualized exercise intensity that avoids excessive hemodynamic stress. Taken together, these findings suggest that early initiation of cardiovascular physical therapy contributes not only to reducing hospital stay but also to improving the overall quality and efficiency of HF management.
Ensuring the early initiation of cardiovascular physical therapy in patients with HF involves several practical and systemic challenges. Patients with prolonged LOS more frequently required intensive interventions such as mechanical ventilation and ICU management, suggesting that they were more severely ill and hemodynamically unstable. Sensitivity analyses demonstrated consistent trends across subgroups defined by MAGGIC score, CFS, and GNRI, supporting the robustness of the association. These findings imply that in patients with more advanced disease burden or nutritional and functional impairment, early rehabilitation may still be beneficial, although clinical decision-making should account for hemodynamic instability and congestion. In such cases, careful assessment of the risk–benefit balance and gradual, stepwise initiation may be warranted. Additionally, logistical factors such as limited staffing resources and delays in physician orders may hinder early initiation. In Japan, cardiovascular physical therapy is reimbursed only under the supervision of a cardiologist or cardiac surgeon, and weekend admissions may result in delayed initiation due to the absence of supervising specialists – representing a structural barrier to early mobilization. Moreover, early mobilization is not universally applicable; excessive rehabilitation intensity in mechanically ventilated or unstable patients may increase the risk of adverse events.22,23 Therefore, early rehabilitation should be implemented only when the expected benefits clearly outweigh potential risks.24
Study Limitations
This study has several limitations. First, as a retrospective observational study, it cannot establish a direct causal relationship between delayed initiation of cardiovascular physical therapy and prolonged LOS. Prospective studies are needed to confirm these findings. Second, because this study was conducted at a single institution, the generalizability of the results to other facilities or healthcare systems, including those outside Japan, may be limited. Third, although we adjusted for major confounders such as disease severity, unmeasured factors – including treatment complexity, baseline physical function, and institutional characteristics – may have influenced the results. Propensity score matching is a valuable method for rigorously balancing baseline differences between early and delayed initiation groups. However, because the present study was a single center with a limited sample size, applying this technique would have substantially reduced the number of analyzable cases and statistical power. Therefore, we prioritized multivariable adjustment. Future large-scale multicenter studies should incorporate propensity score-based methods to enhance causal inference. Last, this study did not assess the content, intensity, or frequency of physical therapy interventions. Previous studies have shown that a greater cardiac rehabilitation volume is significantly associated with improved activities of daily living and reduced institutionalization rates, with longer daily therapy duration contributing to greater improvements in BI scores.25 These findings suggest that both the quantity and quality of rehabilitation may influence ADL recovery and discharge readiness. Future research should include quantitative parameters such as total therapy time and exercise intensity to comprehensively evaluate the impact of cardiovascular physical therapy on clinical outcomes.
Conclusions
This study demonstrated that prolonged hospitalization remains a clinically significant issue in patients with HF, and that initiation of cardiovascular physical therapy on or after hospital Day 3 is associated with prolonged LOS. These findings underscore the importance of assessing hemodynamic stability early and implementing timely, safe cardiovascular physical therapy from the initial phase of hospitalization. Overcoming workforce and organizational barriers and establishing standardized early intervention pathways may help shorten hospital stays, improve patient outcomes, and enhance the efficient use of healthcare resources.
Disclosures
The authors declare that there are no conflicts of interest.
Author Contributions
Conceptualization: C.H., K.K., and T.K.; methodology: C.H., and K.K.; formal analysis: C.H., K.K., and T.K.; investigation: C.H., K.K., K.H., and S.Y.; data curation: C.H., and K.K.; writing – original draft preparation: C.H., K.K., and T.K.; writing – review and editing: C.H., K.K., K.H., and S.Y.; supervision: T.K. All authors have read and agreed to the published version of the manuscript.
IRB Information
This study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Matsushita Memorial Hospital (approval no. 25013).
Acknowledgments
The authors thank Hirofumi Kawamata, Sakiko Honda, and Kuniyasu Harimoto for their support.
Funding Statement
Sources of Funding: The authors received no specific funding for this research.
Data Availability
Deidentified participant data used in this study are available from the corresponding author upon reasonable request. The shared dataset will include data dictionaries, and requests will be considered subject to institutional permissions and ethical review. Data will be available for a period of 5 years from publication and for noncommercial use only.
References
- 1. Harikrishnan S, Sanjay G, Agarwal A, Kumar NP, Kumar KK, Bahuleyan CG, et al.. One-year mortality outcomes and hospital readmissions of patients admitted with acute heart failure: Data from the Trivandrum Heart Failure Registry in Kerala, India. Am Heart J 2017; 189: 193–199. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Wright SP, Verouhis D, Gamble G, Swedberg K, Sharpe N, Doughty RN.. Factors influencing the length of hospital stay of patients with heart failure. Eur J Heart Fail 2003; 5: 201–209. [DOI] [PubMed] [Google Scholar]
- 3. Mitani H, Funakubo M, Sato N, Murayama H, Rached RA, Matsui N, et al.. In-hospital resource utilization, worsening heart failure, and factors associated with length of hospital stay in patients with hospitalized heart failure: A Japanese database cohort study. J Cardiol 2020; 76: 342–349. [DOI] [PubMed] [Google Scholar]
- 4. Omar HR, Guglin M.. Longer-than-average length of stay in acute heart failure: Determinants and outcomes. Herz 2018; 43: 131–139. [DOI] [PubMed] [Google Scholar]
- 5. Kamiya K, Tanaka S, Saito H, Yamashita M, Yonezawa R, Hamazaki N, et al.. Effects of acute phase intensive exercise training in patients with acute decompensated heart failure. JACC Heart Fail 2025; 13: 912–922. [DOI] [PubMed] [Google Scholar]
- 6. Kono Y, Izawa H, Aoyagi Y, Ishikawa A, Sugiura T, Mori E, et al.. Predictive impact of early mobilization on rehospitalization for elderly Japanese heart failure patients. Heart Vessels 2020; 35: 531–536. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Kitai T, Kohsaka S, Kato T, Kato E, Sato K, Teramoto K, et al.; Japanese Circulation Society and the Japanese Heart Failure Society Joint Working Group.. JCS/JHFS 2025 Guideline on diagnosis and treatment of heart failure. Circ J 2025; 89: 1278–1444. [DOI] [PubMed] [Google Scholar]
- 8. Tsutsui H, Isobe M, Ito H, Ito H, Okumura K, Ono M, et al.; Japanese Circulation Society and the Japanese Heart Failure Society Joint Working Group.. JCS 2017/JHFS 2017 Guideline on diagnosis and treatment of acute and chronic heart failure: Digest version. Circ J 2019; 83: 2084–2184. [DOI] [PubMed] [Google Scholar]
- 9. Izawa H, Yoshida T, Ikegame T, Izawa KP, Ito Y, Okamura H, et al.; Japanese Association of Cardiac Rehabilitation Standard Cardiac Rehabilitation Program Planning Committee.. Standard cardiac rehabilitation program for heart failure. Circ J 2019; 83: 2394–2398. [DOI] [PubMed] [Google Scholar]
- 10. Ueno K, Kaneko H, Kamiya K, Okada A, Itoh H, Konishi M, et al.. Association of early acute-phase rehabilitation initiation on outcomes among patients aged ≥90 years with acute heart failure. J Am Geriatr Soc 2023; 71: 1840–1850. [DOI] [PubMed] [Google Scholar]
- 11. Fleming LM, Zhao X, DeVore AD, Heidenreich PA, Yancy CW, Fonarow GC, et al.. Early ambulation among hospitalized heart failure patients is associated with reduced length of stay and 30-day readmissions. Circ Heart Fail 2018; 11: e004634. [DOI] [PubMed] [Google Scholar]
- 12. Formiga F, Chivite D, Manito N, Mestre AR, Llopis F, Pujol R.. Admission characteristics predicting longer length of stay among elderly patients hospitalized for decompensated heart failure. Eur J Intern Med 2008; 19: 198–202. [DOI] [PubMed] [Google Scholar]
- 13. Massari F, Scicchitano P, Ciccone MM, Caldarola P, Aspromonte N, Iacoviello M, et al.. Bioimpedance vector analysis predicts hospital length of stay in acute heart failure. Nutrition 2019; 61: 56–60. [DOI] [PubMed] [Google Scholar]
- 14. Miñana G, Bosch MJ, Núñez E, Mollar A, Santas E, Valero E, et al.. Length of stay and risk of very early readmission in acute heart failure. Eur J Intern Med 2017; 42: 61–66. [DOI] [PubMed] [Google Scholar]
- 15. Whellan DJ, Zhao X, Hernandez AF, Liang L, Peterson ED, Bhatt DL, et al.. Predictors of hospital length of stay in heart failure: Findings from Get With the Guidelines. J Card Fail 2011; 17: 649–656. [DOI] [PubMed] [Google Scholar]
- 16. Kono Y, Sakurada K, Iida Y, Iwata K, Kato M, Kamiya K, et al.. Real-world evidence of feasible assessment and intervention in cardiovascular physical therapy for older patients with heart failure: Insight from the J-Proof HF of the Japanese Society of Cardiovascular Physical Therapy. Circ Rep 2024; 6: 441–447. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Kaneko H, Itoh H, Kamiya K, Morita K, Sugimoto T, Konishi M, et al.. Acute-phase initiation of cardiac rehabilitation and clinical outcomes in hospitalized patients for acute heart failure. Int J Cardiol 2021; 340: 36–41. [DOI] [PubMed] [Google Scholar]
- 18. Okamura M, Kataoka Y, Taito S, Fujiwara T, Ide A, Oritsu H, et al.. Early mobilization for acute heart failure: A scoping and a systematic review. J Cardiol 2024; 83: 91–99. [DOI] [PubMed] [Google Scholar]
- 19. Yagi M, Yasunaga H, Matsui H, Fushimi K, Fujimoto M, Koyama T, et al.. Association between early rehabilitation and mobility status in elderly inpatients with heart failure: A nationwide retrospective cohort study. Prog Rehabil Med 2018; 3: 20180017. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20. Kortebein P, Ferrando A, Lombeida J, Wolfe R, Evans WJ.. Effect of 10 days of bed rest on skeletal muscle in healthy older adults. JAMA 2007; 297: 1772–1774. [DOI] [PubMed] [Google Scholar]
- 21. Tesch PA, von Walden F, Gustafsson T, Linnehan RM, Trappe TA.. Skeletal muscle proteolysis in response to short-term unloading in humans. J Appl Physiol (1985) 2008; 105: 902–906. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22. Hodgson CL, Bailey M, Bellomo R, Brickell K, Broadley T, Buhr H, et al.; TEAM Study Investigators and the ANZICS Clinical Trials Group.. Early active mobilization during mechanical ventilation in the ICU. N Engl J Med 2022; 387: 1747–1758. [DOI] [PubMed] [Google Scholar]
- 23. Patel BK, Wolfe KS, Patel SB, Dugan KC, Esbrook CL, Pawlik AJ, et al.. Effect of early mobilisation on long-term cognitive impairment in critical illness in the USA: A randomised controlled trial. Lancet Respir Med 2023; 11: 563–572. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Unoki T, Hayashida K, Kawai Y, Taito S, Ando M, Iida Y, et al.; Committee for the Clinical Practice Guidelines of Early Mobilization and Rehabilitation in Intensive Care of the Japanese Society of Intensive Care Medicine.. Japanese clinical practice guidelines for rehabilitation in critically ill patients 2023 (J-ReCIP 2023). J Intensive Care 2023; 11: 47. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25. Miyazawa R, Iso Y, Yamamoto S, Matsuo T, Morisawa T, Takahashi T, et al.. Impact of tailored multidisciplinary cardiac rehabilitation on patients with cardiovascular diseases and multimorbidity in convalescent rehabilitation hospitals in Japan: A multicenter, prospective observational study. Circ Rep 2025; 7: 403–410. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Deidentified participant data used in this study are available from the corresponding author upon reasonable request. The shared dataset will include data dictionaries, and requests will be considered subject to institutional permissions and ethical review. Data will be available for a period of 5 years from publication and for noncommercial use only.