Factors associated with lack of improvement in submaximal exercise capacity of patients with heart failure.

AIMS: Improvement in exercise capacity is the primary goal of physical activity programmes for patients with heart failure (HF). Although activity programmes are effective for some patients, others do not benefit. Identifying factors related to a lack of improvement in submaximal exercise capacity may help us interpret findings and design new interventions. The aim of this study is to identify factors contributing to a lack of improvement in submaximal exercise capacity 3 months after physical activity advice or an exergame intervention in patients with HF. Additionally, we aimed to assess differences in lack of improvement in submaximal exercise capacity of patients whose baseline exercise capacity predicted a worse compared with better prognosis of HF. METHODS AND RESULTS: This secondary analysis of the HF-Wii study analysed baseline and 3 month data of the 6 min walk test (6MWT) from 480 patients (mean age 67 years, 72% male). Data were analysed separately in patients with a pre-defined 6 min walking distance at baseline of <300 m (n = 79) and ≥300 m (n = 401). Among patients with a baseline 6MWT of ≥300 m, 18% had deteriorated submaximal exercise capacity. In the multiple logistic regression analysis, lower baseline levels of self-reported physical activity [odds ratio (OR) = 0.77, 95% confidence interval (CI) = 0.60-0.97], lower baseline levels of cognitive function (OR = 0.87, 95%CI = 0.79-0.96) were significantly associated with lack of improvement in exercise capacity at 3 months. Not randomized to exergaming (OR = 0.63, 95%CI = 0.37-1.09) was likely (P = 0.097) to be associated with lack of improvement in exercise capacity at 3 months. Among the 79 patients with baseline 6MWT of <300 m, 41% (n = 32) did not improve 6MWT distance at 3 months. Independent predictors for the lack of improvement for 6MWT were New York Heart Association class III/IV (OR = 4.68, 95%CI = 1.08-20.35), higher levels of serum creatinine (OR = 1.02, 95%CI = 1.003-1.03), lower cognitive function (OR = 0.86, 95%CI = 0.75-0.99), and fewer anxiety symptoms (OR = 0.84, 95%CI = 0.72-0.98). CONCLUSIONS: Lower self-reported physical activity and cognitive impairment predict lack of improvement in submaximal exercise capacity in HF patients. Patients who have a worse prognosis (score <300 m at the 6MWT) are often frail and gain less in exercise capacity. These patients may need a more comprehensive approach to have an effect on exercise capacity, including an individually tailored exercise programme with aerobic exercise (if tolerated) and strength exercises.

Cognitive impairment in patients with heart failure: an international study.

AIMS: Cognitive impairment (CI) in heart failure (HF) patients has mostly been studied in single countries in specific health care settings. Sociodemographic and clinical predictors of the global CI and CI dimensions are still unclear. We described CI in a diverse HF population recruited in several countries and in different health care settings and investigated sociodemographic and clinical factors associated with the global and specific CI dimensions in HF patients. METHODS AND RESULTS: A secondary analysis from the baseline data of the Wii-HF trial. Patients (n = 605) were enrolled in Sweden, Italy, Israel, The Netherlands, Germany, and the United States. We used the Montreal Cognitive Assessment to evaluate CI and the 6 minute walk test (6MWT) to measure exercise capacity. Patients were on average 67 years old (SD, 12), and 86% were in New York Heart Association Class II and III. The mean Montreal Cognitive Assessment score was 24 (SD, 4), and 67% of patients had at least a mild CI. The item evaluating short-term memory had a considerable proportion of low scoring patients (28.1%). Worse CI was associated with patients' older age, lower education, and lower 6MWT scores (R2 = 0.27). CI dimension scores were differently associated with specific clinical and demographic variables, but the 6MWT scores were associated with five out of seven CI dimension scores. CONCLUSIONS: CI is an important problem in HF patients, with specific challenges in regard to memory. Exercise capacity is a modifiable factor that could be improved in HF patients with the potential to improve cognition and other outcomes in this population.

Relationships among measures of physical fitness in adult patients with heart failure.

OBJECTIVES: To describe the relationships among 3 measures of physical fitness (exercise capacity, muscle function and functional capacity) in patients with heart failure, and to determine whether these measures are influenced by impairment of movement. METHODS: Secondary analysis of baseline data from the Italian subsample (n = 96) of patients with heart failure enrolled in a randomized controlled trial, the HF-Wii study. Exercise capacity was measured with the 6-min walk test, muscle function was measured with the unilateral isotonic heel-lift, bilateral isometric shoulder abduction and unilateral isotonic shoulder flexion, and functional capacity was measured with the Duke Activity Status Index. Principal component analysis was used to detect covariance of the data. RESULTS: Exercise capacity correlated with all of the tests related to muscle function (r = 0.691-0.423, p < 0.001) and functional capacity (r = 0.531). Moreover, functional capacity correlated with muscle func-tion (r = 0.482-0.393). Principal component analysis revealed the bidimensional structure of these 3 measures, thus accounting for 58% of the total variance in the variables measured. CONCLUSION: Despite the correlations among exercise capacity, muscle function and functional capacity, these measures loaded on 2 different factors. The use of a wider range of tests will help clinicians to perform a more tailored assessment of physical fitness, especially in those patients with heart failure who have impairment of movement.

Relationships between exercise capacity and anxiety, depression, and cognition in patients with heart failure.

BACKGROUND: Symptoms of anxiety, depression, and cognitive impairment are common in heart failure (HF) patients, but there are inconsistencies in the literature regarding their relationship and effects on exercise capacity. OBJECTIVES: The aim of this study was to explore the relationships between exercise capacity and anxiety, depression, and cognition in HF patients. METHODS: This was a secondary analysis on the baseline data of the Italian subsample (n = 96) of HF patients enrolled in the HF-Wii study. Data was collected with the 6-minute walk test (6MWT), Hospital Anxiety and Depression Scale, and Montreal Cognitive Assessment. RESULTS: The HF patients walked an average of 222 (SD 114) meters on the 6MWT. Patients exhibited clinically elevated anxiety (48%), depression (49%), and severe cognitive impairment (48%). Depression was independently associated with the distance walked on the 6MWT. CONCLUSIONS: The results of this study reinforced the role of depression in relation to exercise capacity and call for considering strategies to reduce depressive symptoms to improve outcomes of HF patients.

Increasing exercise capacity and quality of life of patients with heart failure through Wii gaming: the rationale, design and methodology of the HF-Wii study; a multicentre randomized controlled trial.

AIMS: Exercise is known to be beneficial for patients with heart failure (HF), and these patients should therefore be routinely advised to exercise and to be or to become physically active. Despite the beneficial effects of exercise such as improved functional capacity and favourable clinical outcomes, the level of daily physical activity in most patients with HF is low. Exergaming may be a promising new approach to increase the physical activity of patients with HF at home. The aim of this study is to determine the effectiveness of the structured introduction and access to a Wii game computer in patients with HF to improve exercise capacity and level of daily physical activity, to decrease healthcare resource use, and to improve self-care and health-related quality of life. METHODS AND RESULTS: A multicentre randomized controlled study with two treatment groups will include 600 patients with HF. In each centre, patients will be randomized to either motivational support only (control) or structured access to a Wii game computer (Wii). Patients in the control group will receive advice on physical activity and will be contacted by four telephone calls. Patients in the Wii group also will receive advice on physical activity along with a Wii game computer, with instructions and training. The primary endpoint will be exercise capacity at 3 months as measured by the 6 min walk test. Secondary endpoints include exercise capacity at 6 and 12 months, level of daily physical activity, muscle function, health-related quality of life, and hospitalization or death during the 12 months follow-up. CONCLUSION: The HF-Wii study is a randomized study that will evaluate the effect of exergaming in patients with HF. The findings can be useful to healthcare professionals and improve our understanding of the potential role of exergaming in the treatment and management of patients with HF. TRIAL REGISTRATION: NCT01785121.