The Editor,
We read with great interest the comprehensive consensus document on management of chronic heart failure (HF) recently published in the Indian Heart Journal.1 To elaborate on the rehabilitative aspect, we hereby propose a rehabilitation algorithm for both hospitalized and out-patient, stable HF patients.
Exercise-based evaluations
Evaluation of exercise capacity is a crucial step to the functional assessment of patients with HF. Though the gold standard remains to be cardiopulmonary exercise testing, high costs of establishing labs makes this option unviable in India. Therefore, the use of the six minute walk test to assess the distance covered (6MWD). The test is safe and can be used across all classes of HF. Clinical monitoring using the 6MWD is useful and can be easily done with no extra costs of infrastructure.
Rehabilitation of HF
Participation in exercise training and physical activity for HF is a class I, Level A recommendation.2 Recently, there has been a focus on early rehabilitation of acute HF patients. A previous study from our center found that participation in early cardiac rehabilitation (CR) for acute HF improved discharge 6MWD as compared to those not receiving early CR.3 Discharge evaluations with the 6MWD is important as it would guide exercise prescription following discharge.
Phase-2 CR requires patients to continue exercise either under supervision in a center or at home. With the barriers to CR in the Indian context highlighted in previous studies,4 supervised programs may not always be feasible. Thus, the need for low intensity home based programs which can be administered by an CR exercise specialist to ensure safety. Based on our data and current clinical practice, and on the early CR algorithm proposed for ST elevation myocardial infarction5 we propose a clinical rehabilitation algorithm for HF patients for both early and subsequent phase-2 CR (Fig. 1a and b).
Fig. 1.
In-patient rehabilitation for acute heart failure and Phase-2 cardiac rehabilitation for heart failure.
Legend: HR − Heart rate; RPE − Brog’s Rating perceived exertion
References
- 1.Mishra S., Mohan J.C., Nair T. Management protocols for chronic heart failure in India. Indian Heart J. 2018;70:105–127. doi: 10.1016/j.ihj.2017.11.015. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Yancy C.W., Jessup M., Bozkurt B. ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;62:e147–239. doi: 10.1016/j.jacc.2013.05.019. [DOI] [PubMed] [Google Scholar]
- 3.Babu A.S., Maiya A.G., George M.M., Padmakumar R., Guddattu V. Effects of combined early in-patient cardiac rehabilitation and structured home-based program on function among patients with congestive heart failure: a randomized controlled trial. Heart Views. 2011;12:99–103. doi: 10.4103/1995-705X.95064. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Madan K., Babu A.S., Contractor A., Sawhney J.P., Prabhakaran D., Gupta R. Cardiac rehabilitation in India. Prog Cardiovasc Dis. 2014;56:543–550. doi: 10.1016/j.pcad.2013.11.001. [DOI] [PubMed] [Google Scholar]
- 5.Mishra S., Ramakrishnan S., Babu A.S. Management algorithms for acute ST elevation myocardial infarction in less industrialized world. Indian Heart J. 2017;69(Suppl. 1):S98–s103. doi: 10.1016/j.ihj.2017.03.005. [DOI] [PMC free article] [PubMed] [Google Scholar]