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Physical Rehabilitation for Older Patients Hospitalized for Heart Failure

Dalane W. Kitzman ... 心脑血管疾病 • 2021.07.15
NEJM 动画解读

• sotagliflozin治疗近期心力衰竭恶化的糖尿病患者 • 血管紧张素脑啡肽酶抑制疗法治疗射血分数保留的心力衰竭






我们开展了一项多中心、随机、对照试验,旨在评估涵盖身体功能4个方面(力量、平衡、灵活性和耐力)的过渡性、个体化、渐进式复健干预。干预在患者因心力衰竭住院期间或出院后早期开始,并且患者在出院后继续接受36次门诊治疗。主要结局是3个月时的简易身体功能量表(Short Physical Performance Battery)评分(总分范围为0~12,评分较低表示身体功能障碍较严重)。次要结局是6个月时,全因再住院率。



共计349例患者接受了随机分组;175人被分配接受复健干预,174人被分配接受常规治疗(对照)。基线时,两组患者的身体功能均明显受损,97%的患者身体虚弱或处于虚弱前期(prefrail);两组中合并症的平均种数均为5种。干预组的患者保留率为82%,对干预的依从率为67%。针对基线简易身体功能量表评分和其他基线特征进行校正后,3个月时,干预组和对照组的简易身体功能量表评分的最小二乘均值(±SE)分别为8.3±0.2和6.9±0.2(组间平均差异,1.5;95%置信区间[CI],0.9~2.0;P<0.001)。6个月时,干预组和对照组的全因再住院率分别为1.18和1.28(率比,0.93;95% CI,0.66~1.19)。干预组有21例患者死亡(15例死于心血管原因),对照组有16例患者死亡(8例死于心血管原因)。两组的全因死亡率分别为0.13和0.10(率比,1.17;95% CI,0.61~2.27)。





Dalane W. Kitzman, M.D., David J. Whellan, M.D., M.H.S., Pamela Duncan, P.T., Ph.D., Amy M. Pastva, P.T., Ph.D., Robert J. Mentz, M.D., Gordon R. Reeves, M.D., M.P.T., M. Benjamin Nelson, M.S., Haiying Chen, Ph.D., Bharathi Upadhya, M.D., Shelby D. Reed, Ph.D., Mark A. Espeland, Ph.D., LeighAnn Hewston, D.P.T., M.Ed., and Christopher M. O’Connor, M.D.
From the Department of Internal Medicine, Sections of Cardiovascular Medicine (D.W.K., M.B.N., B.U.) and Gerontology and Geriatric Medicine (D.W.K., M.A.E.), and the Departments of Neurology (P.D.) and Biostatistics and Data Science (H.C., M.A.E.), Wake Forest School of Medicine, Winston-Salem, the Department of Orthopedic Surgery, Doctor of Physical Therapy Division (A.M.P.), the Department of Medicine, Division of Cardiology (R.J.M.), and the Department of Population Health Sciences (S.D.R.), Duke University School of Medicine, Durham, and Novant Health Heart and Vascular Institute, Charlotte (G.R.R.) — all in North Carolina; the Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University (D.J.W.), and the Department of Physical Therapy, Jefferson College of Rehabilitation Sciences at Thomas Jefferson University (L.A.H.) — both in Philadelphia; and Inova Heart and Vascular Institute, Fairfax, VA (C.M.O.). Address reprint requests to Dr. Kitzman at the Department of Internal Medicine, Sections of Cardiovascular Medicine and Gerontology and Geriatric Medicine, Wake Forest School of Medicine, 1 Medical Center Blvd., Winston-Salem, NC 27157-1045, or at dkitzman@wakehealth.edu. A list of the investigators in this trial is provided in the Supplementary Appendix, available at NEJM.org.



1. Heidenreich PA, Albert NM, Allen LA, et al. Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association. Circ Heart Fail 2013;6:606-619.

2. Cheng RK, Cox M, Neely ML, et al. Outcomes in patients with heart failure with preserved, borderline, and reduced ejection fraction in the Medicare population. Am Heart J 2014;168:721-730.

3. Fleg JL. Preventing readmission after hospitalization for acute heart failure: a quest incompletely fulfilled. JACC Heart Fail 2018;6:153-155.

4. Alahdab MT, Mansour IN, Napan S, Stamos TD. Six minute walk test predicts long-term all-cause mortality and heart failure rehospitalization in African-American patients hospitalized with acute decompensated heart failure. J Card Fail 2009;15:130-135.

5. Chiarantini D, Volpato S, Sioulis F, et al. Lower extremity performance measures predict long-term prognosis in older patients hospitalized for heart failure. J Card Fail 2010;16:390-395.

6. Pandey A, Kitzman D, Whellan DJ, et al. Frailty among older decompensated heart failure patients: prevalence, association with patient-centered outcomes, and efficient detection methods. JACC Heart Fail 2019;7:1079-1088.

7. Yang X, Lupón J, Vidán MT, et al. Impact of frailty on mortality and hospitalization in chronic heart failure: a systematic review and meta-analysis. J Am Heart Assoc 2018;7(23):e008251-e008251.

8. Warraich HJ, Kitzman DW, Whellan DJ, et al. Physical function, frailty, cognition, depression, and quality of life in hospitalized adults ≥60 years with acute decompensated heart failure with preserved versus reduced ejection fraction. Circ Heart Fail 2018;11(11):e005254-e005254.

9. Kitzman DW, Haykowsky MJ, Tomczak CR. Making the case for skeletal muscle myopathy and its contribution to exercise intolerance in heart failure with preserved ejection fraction. Circ Heart Fail 2017;10(7):e004281-e004281.

10. Fleg JL, Cooper LS, Borlaug BA, et al. Exercise training as therapy for heart failure: current status and future directions. Circ Heart Fail 2015;8:209-220.

11. Krumholz HM. Post-hospital syndrome — an acquired, transient condition of generalized risk. N Engl J Med 2013;368:100-102.

12. Lorenzo M, de la Espriella R, Miñana G, et al. Clinical profile and 1-year clinical outcomes of super elderly patients admitted with acute heart failure. Eur J Intern Med 2020;81:78-82.

13. Huusko J, Tuominen S, Studer R, et al. Recurrent hospitalizations are associated with increased mortality across the ejection fraction range in heart failure. ESC Heart Fail 2020;7:2406-2417.

14. Gill TM, Allore HG, Gahbauer EA, Murphy TE. Change in disability after hospitalization or restricted activity in older persons. JAMA 2010;2304:1919-1928.

15. Forman DE, Arena R, Boxer R, et al. Prioritizing functional capacity as a principal end point for therapies oriented to older adults with cardiovascular disease: a scientific statement for healthcare professionals from the American Heart Association. Circulation 2017;135(16):e894-e918.

16. O’Connor CM, Whellan DJ, Lee KL, et al. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA 2009;301:1439-1450.

17. Reeves GR, Whellan DJ, Duncan P, et al. Rehabilitation therapy in older acute heart failure patients (REHAB-HF) trial: design and rationale. Am Heart J 2017;185:130-139.

18. Pastva AM, Duncan PW, Reeves GR, et al. Strategies for supporting intervention fidelity in the rehabilitation therapy in older acute heart failure patients (REHAB-HF) trial. Contemp Clin Trials 2018;64:118-127.

19. Reeves GR, Whellan DJ, O’Connor CM, et al. A novel rehabilitation intervention for older patients with acute decompensated heart failure: the REHAB-HF pilot study. JACC Heart Fail 2017;5:359-366.

20. Pavasini R, Guralnik J, Brown JC, et al. Short physical performance battery and all-cause mortality: systematic review and meta-analysis. BMC Med 2016;14:215-215.

21. Soubra R, Chkeir A, Novella JL. A systematic review of thirty-one assessment tests to evaluate mobility in older adults. Biomed Res Int 2019;2019:1354362-1354362.

22. Volpato S, Cavalieri M, Sioulis F, et al. Predictive value of the short physical performance battery following hospitalization in older patients. J Gerontol A Biol Sci Med Sci 2011;66:89-96.

23. Wang W, Wang W, Mosley TH, Griswold ME. A SAS macro for the joint modeling of longitudinal outcomes and multiple competing risk dropouts. Comput Methods Programs Biomed 2017;138:23-30.

24. Acanfora D, Scicchitano P, Casucci G, et al. Exercise training effects on elderly and middle-age patients with chronic heart failure after acute decompensation: a randomized, controlled trial. Int J Cardiol 2016;225:313-323.

25. Mudge AM, Denaro CP, Scott AC, et al. Addition of supervised exercise training to a post-hospital disease management program for patients recently hospitalized with acute heart failure: the EJECTION-HF randomized phase 4 trial. JACC Heart Fail 2018;6:143-152.

26. Scrutinio D, Passantino A, Catanzaro R, et al. Inpatient cardiac rehabilitation soon after hospitalization for acute decompensated heart failure: a propensity score study. J Cardiopulm Rehabil Prev 2012;32:71-77.

27. Babu AS, Maiya AG, George MM, 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.

28. Reeves GR, Whellan DJ, Patel MJ, et al. Comparison of frequency of frailty and severely impaired physical function in patients ≥60 years hospitalized with acute decompensated heart failure versus chronic stable heart failure with reduced and preserved left ventricular ejection fraction. Am J Cardiol 2016;117:1953-1958.

29. Yancy CW, Jessup M, Bozkurt B, et al. 2013 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(16):e147-e239.

30. Forman DE, Fleg JL, Kitzman DW, et al. 6-min walk test provides prognostic utility comparable to cardiopulmonary exercise testing in ambulatory outpatients with systolic heart failure. J Am Coll Cardiol 2012;60:2653-2661.

31. Witham MD, Fulton RL, Greig CA, et al. Efficacy and cost of an exercise program for functionally impaired older patients with heart failure: a randomized controlled trial. Circ Heart Fail 2012;5:209-216.

32. Faber MJ, Bosscher RJ, Chin A Paw MJ, van Wieringen PC. Effects of exercise programs on falls and mobility in frail and pre-frail older adults: a multicenter randomized controlled trial. Arch Phys Med Rehabil 2006;87:885-896.

33. Giallauria F, Vigorito C, Tramarin R, et al. Cardiac rehabilitation in very old patients: data from the Italian Survey on Cardiac Rehabilitation-2008 (ISYDE-2008) — official report of the Italian Association for Cardiovascular Prevention, Rehabilitation, and Epidemiology. J Gerontol A Biol Sci Med Sci 2010;65:1353-1361.

34. Perera S, Mody SH, Woodman RC, Studenski SA. Meaningful change and responsiveness in common physical performance measures in older adults. J Am Geriatr Soc 2006;54:743-749.

35. Flynn KE, Piña IL, Whellan DJ, et al. Effects of exercise training on health status in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA 2009;301:1451-1459.

36. Spertus JA, Jones PG, Kim J, Globe D. Validity, reliability, and responsiveness of the Kansas City Cardiomyopathy Questionnaire in anemic heart failure patients. Qual Life Res 2008;17:291-298.

37. Johnson TJ, Basu S, Pisani BA, et al. Depression predicts repeated heart failure hospitalizations. J Card Fail 2012;18:246-252.

38. Contrepois K, Wu S, Moneghetti KJ, et al. Molecular choreography of acute exercise. Cell 2020;181(5):1112-1130.e16.

39. Davies EJ, Moxham T, Rees K, et al. Exercise training for systolic heart failure: Cochrane systematic review and meta-analysis. Eur J Heart Fail 2010;12:706-715.

40. Reed SD, Fairchild AO, Johnson FR, et al. Patients’ willingness to accept mitral valve procedure-associated risks varies across severity of heart failure symptoms. Circ Cardiovasc Interv 2019;12(12):e008051-e008051.

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