BARRIERS FOR CARDIAC REHABILITATION IN HEART FAILURE: HOW TO IMPROVE ADHERENCE

Abstract

Introduction: Despite a variety of pharmacological and device therapies for heart failure (HF), patients still have a poor prognosis and quality of life. Lifestyle modifications, cardiac rehabilitation (CR) and regular exercise, have been shown to help manage HF symptoms and improve cardiac function. However, despite all the scientific evidence and clinical recommendations, CR is underutilized in the treatment of HF. The reasons for the underutilization of CR programs are multifactorial and include health system, health professionals or patient barriers. It is important to address these barriers to increase participation and adherence to ensure that everyone who could benefit from CR has the opportunity to participate. In light of this, home-based CR (HBCR) alone or in combination with clinical-based CR (CBCR), have the potential to address some barriers such as schedule flexibility, time commitment, travel distance, cost and patient preference. In addition, the higher degree of self-monitoring/management required in home-based programs, may promote a favorable transition to sustainable behavioral change and disease self-management. Long-term adherence to exercise training after CR phase 2 can be challenging, but it is critical to maintaining cardiovascular health and reducing the risk of future cardiac events. Thus, considering the importance of CR programs in the treatment of patients with HF, the low accessibility and adherence to this type of program, as well the long-term adherence, it is necessary to understand the reasons for this underutilization in the context of the Portuguese population. Objective: In the present work we propose: i) to describe and compare the barriers to participation in a clinical versus home-based CR program in patients with HF in a public hospital in Portugal; ii) to investigate whether these barriers were related to adherence to the CR program; iii) to assess the effectiveness of the home-based CR on exercise adherence and physical fitness after phase II CR in HF patients; iv) to compare long-term effects of a home-based vs clinical-based CR intervention; and v) to propose the implementation of a specialized community phase III CR program to help cardiac patients achieve a healthy lifestyle, manage optimal cardiovascular risk factors, and promote wellness after phase II CR. Methods: To achieve the proposed objectives, we evaluated 87 patients with HF in Study I and 54 patients with HF in Study II. In study I, the Barriers to Cardiac Rehabilitation Scale questionnaire was used to assess patients' perception of the degree to which different barriers affected their participation in a CR program. In addition, adherence data were collected from exercise session records and the heart rate monitor device. In Study II, patients were assessed for physical activity (IPAQ short version and the heart rate monitor, model POLAR M200) and physical fitness (6-minute-walking test (6MWT), 8-foot-up-and-go test, handgrip and 30-second sit-to-stand test). Study III is a phase III CR protocol to be implemented within the community. Results: In Study I, our data indicate that other health problems are the main barrier for patients with HF. Comparing with CBCR group, the HBCR participants rated two main barriers significantly higher, such as "bad weather" and "I have little time", but it not reflected in adherence rates. In Study II, our data suggests that HBCR program did not resulted in better adherence to long-term physical activity or fitness levels compared with the CBCR intervention. Finally, in Study III, we propose a phase III CR program within the community, with group allocation according to preference, to respond to unmet health and social challenges regarding maintenance after phase II CR. Conclusions: Our data suggest that after identifying barriers related with CR participation and adherence, an individualized CR programs that incorporates patient's-specific barriers would impact on CR participation. In addition, 12 weeks of a HBCR or CBCR program appears to be not enough to promote a transition to sustainable behavior change over time. Finally, new a specialized community-based phase III CR programs are needed to help cardiac patients achieve a sustainable healthy lifestyle, manage optimal cardiovascular risk factors, and promote wellness after phase II CR.