Mount Carmel Congestive Heart Failure Exercise and Lifestyle Modification Program
By: Rachel Fetrow, Allison Mazzulo, and Tammy Garwick
Sponsored by St. Jude Medical Foundation
According to the AHA, congestive heart failure is the most common Medicare DRG, costing more Medicare dollars than any other diagnosis. Total estimated cost in 2006 was over 29 billion dollars--3 billion of those dollars in drug costs.
Heart failure is a syndrome, characterized by elevated filling pressure and/or inadequate peripheral oxygen delivery, at rest or during stress, caused by cardiac dysfunction. Heart failure is a growing problem in the United States, currently affecting over 5 million people and contributing to 300,000 deaths each year (National Heart, Lung and Blood Institute/NHLBI). It is primarily a disease of the elderly, affecting 10% of the U.S. population over 70. However, 7% of the US population affected by heart failure is between ages 40-69.
The fatality rate for patients living with heart failure is high, with 1 in 5 persons dying within the first year of diagnosis and only 20 percent living between 8-12 years after diagnosis. Sudden death is common and occurs at a rate six to nine times that of the general population (NHLBI). The goal of our program was to help reduce these staggering statics by incorporating a fitness routine into the heart failure patient’s already medically managed care, with the intention of improving the heart’s function through aerobic exercise and reinforced through lifestyle modification.
Our patient population was selected through Mount Carmel’s Outpatient Heart Failure clinic, by the nurse practitioner that follows the patients’ care. We also received direct physician referrals through Mount Carmel’s Cardiac Rehabilitation Medical Director. Our plan of care was based on a research study done by Ole Johan Kemi PhD, and Ulrik Wisloff PhD, published in the Journal of Cardiopulmonary Rehabilitation and Prevention. We also used information from the Norwegian Ulleval Model, a method based on case reports out of Ullevaal University Hospital in Oslo, Norway. These two studies show that repeated bouts of high-intensity exercise of variable length, interspersed with recovery periods, allows the heart failure patient to achieve a higher increase in exercise capacity than can be achieved with a continuous-exercise model. The standard for determining intensity is to obtain a peak VO2 during a cardiopulmonary exercise test. The Norwegian Ullevaal Model used peak VO2 to determine the high level of intensity for each individual. The patient was then exercised at 90-95% of their measured maximum heart rate from the peak metabolic test (or a 15-18 on the Borg’s Scale of perceived exertion during the high-intensity interval), and then 50-60% of maximum heart rate (or 11-13 on the Borg Scale). Due to equipment constraints, our method was modified. We used a sub maximal walking test on the treadmill to determine at what metabolic equivalent of task (MET) level the patient rated the test a 14 on Borg’s Scale. We then used the patient’s heart rate at that maximum MET level, as our baseline for the high-intensity level. The recovery period was then determined by the patient rating of an 11 on Borg’s Scale. As the patient’s functional capacity increased, MET level was adjusted to maintain a rating of 14 on Borg’s scale, while staying within the limit of 85% of maximum age predicted heart rate.
The Kansas City Cardiomyopathy Questionnaire was chosen to measure health-related quality of life related to heart failure. It is a 23 item questionnaire that quantifies physical function, heart failure symptoms (frequency, severity and recent change), social function, self-efficacy, knowledge, and quality of life. Patients took the questionnaire pre and post program. The questionnaire results in a total symptom score, a clinical summary score and an overall summary score. Each patient completed the questionnaire before beginning the program and again on the last session before graduation. Results were then compared to help determine how the exercise improved their overall symptoms.
To screen for depression, we chose the PHQ-9 scale. The PHQ-9 is the nine item depression scale of the Patient Health Questionnaire, and it is a powerful tool for assisting clinicians in diagnosing depression, as well as selecting and monitoring treatment. The PHQ-9 is based directly on the diagnostic criteria for major depressive disorder in the Diagnostic and Statistical Manual Fourth Edition (DSM-IV). We also used this tool at the beginning and end of the program.
Finally, educational classes were taught in a group setting during the exercise sessions, by either a nurse or an exercise physiologist. These classes were introductory lessons to help each patient become more independent in symptom management and more knowledgeable about efficacy and safety in exercise and diet modification. Each patient also had the opportunity to attend five additional classes in a group class setting separate from the exercise session. These five classes covered nutrition, medications and stress management, and were taught by specialists in the field. Each patient was able to have an individual consultation with the dietitian to have personalized nutritional modification recommendations. To help evaluate an increase in knowledge in dietary habits, each patient completed a 10 question diet questionnaire at the beginning and end of their program.
Our patient population included 10 participants, 43% female and 57% male. The average age was 62.6 years. We had 3 patients drop out of the program prior to completion. One patient dropped out due to transportation issues, one due to other medical complications and the third due to non-compliance/non-attendance. Of those that completed the program, the compliance rate was 92% in regards to attendance of the allowable 26 sessions (twice weekly for 13 weeks). We allowed a rolling admission and the program ran from July 2010 until December 2010. The data to follow represents the 7 patients that completed the program.
The average pre-program ejection fraction was 32%, and the average post-program ejection fraction was 42.4% -- an increase of 24.2%. Ejection fractions were obtained from echocardiogram data as performed by each patient’s personal cardiologist.
The average resting heart rate pre-program was 75 bpm and post-program was 81 bpm -- an increase of 7.8%. The average pre-program resting systolic blood pressure (SBP) was 135.7 mm Hg, and the average post-program resting SBP was 127.4 mm Hg -- a decrease of 6.5%. The average pre-program resting diastolic blood pressure (DBP) was 67.4 mm Hg, and the average post-program resting DBP was 69.7 mm Hg -- an increase of 3%.
The pre and post-program exercise MET level was measured by estimating the MET level obtained at a rating of perceived exertion of “14” on the Borg scale, during a sub-maximal ramp-style Bruce protocol treadmill test. The pre-program exercise MET level averaged 4.5 METs, and the post-program exercise MET level averaged 5.3 METs -- an increase of 15%.
The average pre-program body weight for participants was 217.7 pounds and post-program the average was 218.9 pounds, an increase of 1%. The pre-program average waist measure was 42 inches and the post-program average waist measure was 41.5 inches, a decrease of 1%. Waist measure was defined as the narrowest part of the torso between the xyphoid process and the umbilicus.
The Kansas City Cardiomyopathy Questionnaire total symptom score pre-program average was 82.1 and post-program average was 80.8, representing a 1.6% decrease in this area. The clinical summary score averaged 80.1 pre-program and 84.2 post-program, representing a 5.1% increase. The overall summary score pre-program averaged 69.3 and post-program it averaged 87.8, a 26.7% increase. An increase in points of this questionnaire represents an improvement in heart failure symptoms.
The PHQ-9 is a nine item questionnaire that screens for clinical depression. A decrease in score represents an improvement in depressive symptoms. The pre-program average PHQ-9 score was 5.6 and the average post-program PHQ-9 score was 2.7, a decrease of 105%.
We have learned valuable insight from providing this service to these patients. We are quite impressed with the outcomes associated with the program. Not only are there improvements in the functioning of the participants, but it is equally important that the quality of life demonstrated a 26.7% improvement and the depression scores improved by 105%. These are improvements that are unable to have a monetary value associated with them, yet the participant leaves with a lifelong understanding of cardiac health. We are proud to continue to focus on this underserved population, we and plan to continue to improve the services that are offered to the participants.