Effects of the HEART Camp Trial on Adherence to Exercise in Patients With Heart Failure

doi:10.1016/j.cardfail.2018.06.007

Journal of Cardiac Failure

Volume 24, Issue 10, October 2018, Pages 654-660

https://doi.org/10.1016/j.cardfail.2018.06.007 Get rights and content

Highlights

•
The HEART Camp intervention significantly improved adherence to exercise at 12 and 18 months.
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The intervention treatment effect did not differ based on patient's age, race, gender, marital status, type of heart failure (HF; preserved or reduced ejection fraction,) or NYHA functional class.
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Left ventricular ejection fraction (LVEF) significantly moderated the treatment effect with greater adherence at higher LVEF.
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Adherence levels remained modest, indicating a need for additional research to address methods and strategies to promote adherence to exercise in patients with HF.

ABSTRACT

Background

Few exercise training studies in patients with heart failure (HF) report adherence to guideline-recommended 150 minutes of moderate-intensity exercise per week, and no studies have focused on a primary outcome of adherence.

Methods and Results

This randomized controlled trial evaluated the effect of a multicomponent intervention, Heart Failure Exercise and Resistance Training (HEART) Camp, on adherence to exercise (after 6, 12, and 18 months) compared with an enhanced usual care (EUC) group. Patients (n = 204) were 55.4% male, overall average age was 60.4 years, and 47.5% were nonwhite. The HEART Camp group had significantly greater adherence at 12 (42%) and 18 (35%) months compared with the EUC group (28% and 19%, respectively). No significant difference (P > .05) was found at 6 months. The treatment effect did not differ based on patient's age, race, gender, marital status, type of HF (preserved or reduced ejection fraction) or New York Heart Association functional class. Left ventricular ejection fraction (LVEF) significantly moderated the treatment effect, with greater adherence at higher LVEF.

Conclusions

The multicomponent HEART Camp intervention showed efficacy with significant effects at 12 months and 18 months. Adherence levels remained modest, indicating a need for additional research to address methods and strategies to promote adherence to exercise in patients with HF.

Section snippets

Design

A prospective randomized 2-group repeated-measures experimental design with 4 data collection points (baseline and 6, 12, and 18 months) was used. Subjects were randomized to the 2 groups and stratified by site and gender. The 2010 HFSA guidelines recommend moderate-intensity exercise training in a supervised setting; therefore, both groups (EUC and HC) received 9 supervised exercise training sessions during a 3-week run-in period and were instructed to then continue to exercise in the setting

Statistical Analysis

A power analysis was completed with the use of levels of adherence from HF-ACTION¹⁴ and our own pilot study data. An adherence level of 25% was the level of crossover in HF-ACTION for the control group, and reported adherence in the exercise group was 38% at 12 months and 0.36 at 18 months. Our pilot study data achieved adherence of 86% at 3 months in the intervention group, so we expected to achieve adherence of ≥50% at 18 months. A 1-tailed z test of the difference in proportions of 50% would

Results

Descriptive statistics for the primary outcomes of the study are presented in Table 1. Of the 204 patients included in the analysis, there were 113 men (55.4%) and 91 women (44.6%), with an overall average age of 60.4 years (SD 11.5). There were 165 subjects (80.9%) with HF with reduced ejection fraction and 39 with HF with preserved ejection fraction. Ninety-one of the 95 (19.1%) non-white subjects were African-American. The majority of subjects were NYHA functional class II or III (n = 186;

Discussion

Using the multicomponent HEART Camp intervention, this was the first randomized controlled trial to examine adherence in a diverse sample of patients with HF and showed efficacy with significant effects at 12 months (42% adherent compared with 28% in EUC) and at 18 months (35% adherent compared with 19%). There was no difference in adherence between the HC (37% adherent) and EUC (32% adherent) groups at 6 months. This finding at 6 months suggests that giving patients access to a facility and

Disclosures

None.

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Cited by (21)

The HEART Camp Exercise Intervention Improves Exercise Adherence, Physical Function, and Patient-Reported Outcomes in Adults With Preserved Ejection Fraction Heart Failure
2022, Journal of Cardiac Failure
Citation Excerpt :
All participants provided written informed consent and the institutional review board at each site approved the study and provided oversight. The CONSORT diagram with screening and randomization details has been published previously.22 Randomization was stratified by site and sex.
Despite exercise being one of few strategies to improve outcomes for individuals with heart failure with preserved ejection fraction (HFpEF), exercise clinical trials in HFpEF are plagued by poor interventional adherence. Over the last 2 decades, our research team has developed, tested, and refined Heart failure Exercise And Resistance Training (HEART) Camp, a multicomponent behavioral intervention to promote adherence to exercise in HF. We evaluated the effects of this intervention designed to promote adherence to exercise in HF focusing on subgroups of participants with HFpEF and heart failure with reduced ejection fraction (HFrEF).
This randomized controlled trial included 204 adults with stable, chronic HF. Of those enrolled, 59 had HFpEF and 145 had HFrEF. We tested adherence to exercise (defined as ≥120 minutes of moderate-intensity [40%–80% of heart rate reserve] exercise per week validated with a heart rate monitor) at 6, 12, and 18 months. We also tested intervention effects on symptoms (Patient-Reported Outcomes Measurement Information System-29 and dyspnea-fatigue index), HF-related health status (Kansas City Cardiomyopathy Questionnaire), and physical function (6-minute walk test). Participants with HFpEF (n = 59) were a mean of 64.6 ± 9.3 years old, 54% male, and 46% non-White with a mean ejection fraction of 55 ± 6%. Participants with HFpEF in the HEART Camp intervention group had significantly greater adherence compared with enhanced usual care at both 12 (43% vs 14%, phi = 0.32, medium effect) and 18 months (56% vs 0%, phi = 0.67, large effect). HEART Camp significantly improved walking distance on the 6-minute walk test (η² = 0.13, large effect) and the Kansas City Cardiomyopathy Questionnaire overall (η² = 0.09, medium effect), clinical summary (η² = 0.16, large effect), and total symptom (η² = 0.14, large effect) scores. In the HFrEF subgroup, only patient-reported anxiety improved significantly in the intervention group.
A multicomponent, behavioral intervention is associated with improvements in long-term adherence to exercise, physical function, and patient-reported outcomes in adults with HFpEF and anxiety in HFrEF. Our results provide a strong rationale for a large HFpEF clinical trial to validate these findings and examine interventional mechanisms and delivery modes that may further promote adherence and improve clinical outcomes in this population.
: URL: https://clinicaltrials.gov/. Unique identifier: NCT01658670
Implications for clinical practice from a multicenter survey of heart failure management centers
2021, Clinics
Citation Excerpt :
However, according to the updated Cochrane review, exercise-based rehabilitation reduces the risk of hospital admissions and confers important improvements in health-related quality of life. However, it is important to consider that the availability of rehabilitation services does not mean that a high percentage of patients are actually under rehabilitation because the adherence rate to exercise is usually modest (20). In addition, our survey showed that instructions for exercise were one of the most difficult to provide.
This observational, cross-sectional study based aimed to test whether heart failure (HF)-disease management program (DMP) components are influencing care and clinical decision-making in Brazil.
The survey respondents were cardiologists recommended by experts in the field and invited to participate in the survey via printed form or email. The survey consisted of 29 questions addressing site demographics, public versus private infrastructure, HF baseline data of patients, clinical management of HF, performance indicators, and perceptions about HF treatment.
Data were obtained from 98 centers (58% public and 42% private practice) distributed across Brazil. Public HF-DMPs compared to private HF-DMP were associated with a higher percentage of HF-DMP-dedicated services (79% vs 24%; OR: 12, 95% CI: 94-34), multidisciplinary HF (MHF)-DMP [84% vs 65%; OR: 3; 95% CI: 1-8), HF educational programs (49% vs 18%; OR: 4; 95% CI: 1-2), written instructions before hospital discharge (83% vs 76%; OR: 1; 95% CI: 0-5), rehabilitation (69% vs 39%; OR: 3; 95% CI: 1-9), monitoring (44% vs 29%; OR: 2; 95% CI: 1-5), guideline-directed medical therapy-HF use (94% vs 85%; OR: 3; 95% CI: 0-15), and less B-type natriuretic peptide (BNP) dosage (73% vs 88%; OR: 3; 95% CI: 1-9), and key performance indicators (37% vs 60%; OR: 3; 95% CI: 1-7). In comparison to non- MHF-DMP, MHF-DMP was associated with more educational initiatives (42% vs 6%; OR: 12; 95% CI: 1-97), written instructions (83% vs 68%; OR: 2: 95% CI: 1-7), rehabilitation (69% vs 17%; OR: 11; 95% CI: 3-44), monitoring (47% vs 6%; OR: 14; 95% CI: 2-115), GDMT-HF (92% vs 83%; OR: 3; 95% CI: 0-15). In addition, there were less use of BNP as a biomarker (70% vs 84%; OR: 2; 95% CI: 1-8) and key performance indicators (35% vs 51%; OR: 2; 95% CI: 91,6) in the non-MHF group. Physicians considered changing or introducing new medications mostly when patients were hospitalized or when observing worsening disease and/or symptoms. Adherence to drug treatment and non-drug treatment factors were the greatest medical problems associated with HF treatment.
HF-DMPs are highly heterogeneous. New strategies for HF care should consider the present study highlights and clinical decision-making processes to improve HF patient care.
To Invest or Divest – Tough Choices in the Wake of VEST
2018, Journal of Cardiac Failure
Exercise-based cardiac rehabilitation for adults with heart failure
2024, Cochrane Database of Systematic Reviews
A scale for measuring home-based cardiac rehabilitation exercise adherence: a development and validation study
2023, BMC Nursing
Technology Usage, Physical Activity, and Motivation in Patients with Heart Failure and Heart Transplantation
2023, CIN - Computers Informatics Nursing

View all citing articles on Scopus

: Funding: National Heart Lung and Blood Institute of the National Institutes of Health (award no. R01HL112979). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

View full text

Clinical TrialsEffects of the HEART Camp Trial on Adherence to Exercise in Patients With Heart Failure

Highlights

ABSTRACT

Background

Methods and Results

Conclusions

Section snippets

Design

Statistical Analysis

Results

Discussion

Disclosures

Heart Lung

J Card Fail

Arch Phys Med Rehabil

Appl Nurs Res

Am Heart J

Am Heart J

J Am Coll Cardiol

HFSA 2010 comprehensive heart failure practice guideline

J Card Fail

Compliance with nonpharmacological recommendations and outcome in heart failure patients

Eur Heart J

Compliance behaviors of elderly patients with advanced heart failure

J Cardiovasc Nurs

Exercise self-efficacy in older women with diastolic heart failure: Results of a walking program and education intervention

J Gerontol Nurs

Patients’ experiences of physical limitations in daily life activities when suffering from chronic heart failure; a phenomenographic analysis

Scand J Caring Sci

Self-care behaviour of patients with heart failure

Scand J Caring Sci

Women's and men's exercise adherence after a cardiac event. does age make a difference?

Res Gerontol Nurs

Clinical Trials
Effects of the HEART Camp Trial on Adherence to Exercise in Patients With Heart Failure