Does functional capacity and quality of life improve less in heart failure patients than other cardiac during rehabilitation? 1.0 Introduction 1.1 Heart Failure 1.1.1 Disease Overview (HF) is the heart’s impaired ability to deliver blood oxygen body. HF a multi-organ condition since pump dictates function organs. Left-side-(LHF) Right-Side- (RHF) Biventricular (BVHF) occur acutely due arrhythmia or myocardial damage chronically congenital conditions long term risk factors e.g. chronic hypertension (Institute for Quality Efficiency Health Care 2018). Blood supply body are limited LHF whereas RHF restricts return deoxygenated lungs. result systolic and/ diastolic declivity. In dysfunction ejection fraction reduced ventricular action also referred as with (<35%) Ejection Fraction (HFrEF). preserved restricted filling. This therefore (HFpEF). increases pulmonary pressure causing fluid accumulation (oedema) dyspnoea. venous pressure leading oedema extremities. amassing fluids congestive (CHF) (American Association 2017). 1.1.2 Prevalence admissions at UK hospitals have risen by one third 2014 placing more strain on NHS breast lung prostate bowel cancers combined (Blake 2019). Globally incurable costs $108bn (Kolominsky Kriza & Leysuk The prevalence has increased improved survivability cardiovascular trauma better treatment that ultimately development diabetes. Cardiac problems cause deaths cancer survivors cardiotoxicity caused chemotherapy (Gongora Nair 2016). cost acute survival does not negate mortality may explain why eighty percent ninety HF-related elderly (age= >65) (Kolominsky et al. Forty five comorbidities its nature progression their effect medication (Adam 1.1.3 Prognosis can be bleak. limiting medical management reduce sudden death extend expectancy but it (Mayo Clinic A combination medication surgery implantable devices tends used treatment. experience severe fatigue breathlessness daily activity rehabilitation (CR) health-related however poor evidence makes this inconclusive (Bridges 1.2 Rehabilitation 1.2.1 Definition Purpose Rehab defined as “The co-ordinated sum activities required influence favourably underlying disease well provide best possible physical mental social conditions so may own efforts preserve resume optimal functioning community through health behaviour slow reverse disease” (BACPR 2017 p.1). Despite reported benefits CR just half eligible attend average completion rate seventy seven percent +1% year-on-year (British Foundation proportion remains constant number participating 11983 Seven 81000 CR 2018/2019 had diagnosed cardiomyopathy. 1.2.2 Patients seeks those (NHLBI 2016) hospitalisation (Ciani Davos Piepoli Smart Taylor Walker Warren should measure changes lifestyle factors psychosocial p.8). Aerobic exercise intolerance characteristic reliable indicator status (Fishman Janicki Kinasewitz Weber 1982). strength training been shown benefit HFrEF when 36 sessions were performed over 12 weeks (Van Iterson Seventy meet minimum requirements post-CR. two - group largest increase participation 2019 p.42) thirteen fail complete CR. Those complex highest chance non-completion make most significant levels if they do succeed. Exercise contributes reduction BMI which key factor HF. Low (<18.5kg/m2) strong predictor positive VO2max change (Arakawa 2019) although category an (Finn 2007). 1.3 Outcomes 1.3.1 Functional Capacity Tolerance main patients. (Hanson 1994). be “Designed specifically physical fitness” p.9). Peak VO2 tolerance gas analysis requires staff patient familiarisation furthermore learning protocol affect results significantly (Lainchbury Richards 2002). Measuring Metabolic Equivalent Task (METs) appropriate determined multiple testing protocols compared chosen based patient’s ability. Determining peak asymptomatic METs indicates work thus safely participate without exceeding prescribed intensity level (Blumchen Jette Sidney 1990). One MET equivalent uptake 3.5ml/kg/min measuring provides both physiological description each individual. improvement influenced several measured pre-exercise indicate including Resting Rate (preRHR)(Li Zhang Wang 2016) (preSBP) initial (preMETs) age (preAge) waist circumference (preWC) Body Mass Index (preBMI). Lag time between pre post assessments improvement. 1.3.2 Life (QOL) Anxiety Depression psychosomatic QOL. It important alleviate symptoms anxiety QOL (Gerogianni Leventzonis Panoutsopoulos Polikandrioti Saroglou Thomai Tsami Evidence support drug therapy (Herrmann-Lingen 2011) anxiety depression confidence (Buys Jayasinghe Sun 2014). Clinicians encouraged interventions palliative. scores roughly correlated NYHA classification some framework symptom even disease-specific necessarily correlate (Cowie Gallagher Lucas commonly assessed questionnaires there many valid options. Minnesota Living Questionnaire (Cohn Kubo Rector 1993) specific study non-specific tool Dartmouth COOP still proven validity reliability (Eaton Fergusson Garrett Kolbe Young 2005). --INTRO WORD COUNT 1047-- 2.0 Aims Hypotheses 2.1 Aim Project To establish whether difference diagnoses. 2.2 H0 no H1 3.0 Methods 3.1 Participants 2 years data (n=367) was analysed IBM SPSS Statistics v.25. Data collected from throughout cycle referral discharge. cohorts 18-19 (n=224) 19-20 (n=144) treated single population made intervention 2018 2020. All event 3.2 Collection Anonymised requested senior SRFT Rehabilitation. 3.3 Analysis CSV imported SPSS. String variables recoded subsequent processing order calculate proportions descriptive statistics. Descriptive (univariate/ continuous variables) frequencies (categorical generated quick reference. Variables computed detail measures (IMscores) under consideration course following improvements calculated: FET Score HADS Systolic Pressure Diastolic Grip Strength Shapiro Wilk test normality post. null hypothesis rejected (p<0.05) rejected. Non-parametric confirmed Q-Q plots histogram samples n>200 Central Limit Theorem renders tests inconsequential. statistics IMscores generated. For range located >3 standard deviations mean excessive Kurtosis. Box presence outliers extreme outliers. filtered exclude cases where post-exercise missing. then identified any further individually determine genuine. Missed excluded. Filtration resulted sample size (n= 160) fewer diagnosis groups (n=13 n=9) Kurtosis range variance deviation every IM score. Whilst removed insufficient post-hoc data. resultant renamed Populationr. goal (MET-IMscore) primary all measures. satisfies four assumptions necessary use Kruskal-Wallis compare MET-IMscores groups. continuous <2 within independent variable independence observations. Homogeneity Variance (HoV) assumed assumption tested. Levene’s HoV suitable parametric non-parametric here (One-Way ANOVA rank scores). ranked aggregated score group. differences groups absolute Improvement (abs_MET_Dif) calculated. One-Way abs_MET_Dif variances homogenous p<0.05). despite mean-rank rather median-rank interpret results. H Chi-Square value facilitating calculation using: Effect Size = H/ (N-1) calculated quantify extent significance diagnosis. understand reason measurements could impact: Pre-Exercise Post-Exercise Assessments Number Sessions Pressure Rate Index Waist Circumference Age Event comparison means these conducted identify obvious differences. Kruskal Wallis-H again three together impacted Improvement same process Shapiro-Wilk Test. repeated pairs location Finally participants 4.0 Results Table 1. Quantifying population. 2: Patient frequency 3: Test 4: Figure 1: plot contributing erratic skewness kurtosis 5: IMScores (Populationr) exclusion errors missed cases. 6: Frequency per 7: Normality Populationr confirming distribution way Shapiro-Wilk. Depiction grouped Line graph depicting 8: assess homogeneity 9: ranks MET_Improvement 10: (eta2)= eta2 16.589 155 eta2= 0.107 Bar Graph 11: Comparison Failure NSTEMI Valve 12: potential impact 13: facilitate Kruskal-Walis potentially affecting across P>0.05 assumed. 14: 15: dependent 16: comparing compounding influencing There RHR valve replacement 17: confounding 18: programme attended results? 19: Description programmes 20: 21: Discussion How “effective” defined? Significant HF Groups Only explanation RHR. Indicator start training lower point disease patients? What tell us about status? relationship DBP Are give rounded view progress future actions taken regards to: Research Programme design failure? infection rebound tests. partially temporary ACE inhibitors (most CCB) act performance enhancer threshold Most tend high males really elderley women Fear pushing themselves else affects characteristics (see categories) rehab light classes older Submaximal effort all-cause undergoing rehabilitation. https://www.ncbi.nlm.nih.gov/pubmed/17492677 Majority won’t attack until 70 because hormones protect them convergence CV narrowing arteries affected background categories) https://academic.oup.com/eurheartj/article/31/16/1967/433769 INHIBITOR AFFECT** gold Pre load after total HR BP go up faster Performance enhancement bigger pipes (RHR) CVD general populations recurrence balance sympathetic parasympathetic (Li Since syndrome concurrent function-of contributor. overactivity resulting shortened diastole stroke volume mechanical stress ischaemic episodes. greater atrial fibrillation characterised racing organ RHR>90 beats minute (Li al Beta Blockers 20-30BPM attenuate response limit Function (Abraham 2009). Twenty found exhibit abnormal (n=651) pre-CR sixty either experienced normalisation peri- post-CR (Arad Freimark Hecht Klempfner Abnormal negative implications function comorbidity risk. SBP Define Measures 1.3.3 Other stuff i include (WC) correlates central obesity impacts cardiometabolic (Allison Heymsfield Kahn Kelley Klein Leibel Nonas Anthropometry men. WC (BMI) related Global Longitudinal Strain (GLS) LV (Aguilar Bello Butler Cheng Claggett Coresh Folsom Gupta Kitzman Ndumele Roca Santos Shah Solomon Vardeny Obesity categorised fat percentage (BF%) WC women. 1.4 Intervention modalities Medium Intensity Continuous Training (MICT) High Interval (HIIT) meta left remodelling clinically stable (Beaudry Clark Ellingsen Haykowsky Liang Nelson Tomczak Tucker Notably MICT HIIT Left Ventricular (LVEF) (+6.26% +3.70% respectively) trails >6months duration only modest LVEF shorter trials (<6 months). indicated addition resistance training. guidelines 5 days week (ACSM 2013). attendees end p.39) HRrEF patients’ falls short (mean=11.1 weeks SD= ±2.5 weeks) p.32). When questioning effectiveness must considered. success such questionnaire scores Hospital Scale plus anthropometry change. References Abraham W. Chin M. Feldman A. Francis G. Ganiats T. Hunt Jessup Konstam Mancini D. Michl K. Oates J. Rahko P. Silver Stevenson L. Yancy C. (2009). 2009 focused update incorporated into ACC/AHA 2005 Guidelines Diagnosis Management Adults: report American College Cardiology Foundation/American Association Force Practice Guidelines: developed collaboration International Society Lung Transplantation. Circulation. 119 (14) p. 391-479. Adam Blozik E. Boczor S. Eisele Herrmann-Lingen C. Rakebrandt Scherer Stork Trader J. (2018). Importance care failure—Baseline observational RECODE-HF Study. Family Practice. 35 (4) p.481-487. Allison R. Leibel (2007). Circumference Cardiometabolic Risk. Diabetes Care. 30 (6) p.1647-1652. Aguilar N. B. Solomon O. (2016). Weight Composition Structure ARIC Study (Atherosclerosis Risk Communities). Circulation Failure. 9 (8) pii: e002978. doi: 10.1161/CIRCHEARTFAILURE.115.002978. Sports Medicine (2013). ACSM's Testing Prescription. 9th ed. USA: Lippincott Williams Wilkins. P214-217. Association. (2017). Types Available: https://www.heart.org/en/health-topics/heart-failure/what-is-heart-failure/types-of-heart-failure. Last accessed 19th January Arad Hecht I. R. dynamics patients.. European Journal Preventive Cardiology. 24 p.818-824. Arakawa Fukui Goto Y. Kumasaka Marume Nakanishi Nakao Noguchi Takashio Yanase Yasuda S. (2019). Efficacy With Index. 83 (2) p.334-341. BACPR Standards Core Components Cardiovascular Prevention. 3rd London: British Society. p.1. Beaudry O. Tomczak W. Meta-analysis Reduced Fraction: 10-year Update. Progress Disease. 62 p163-171. Blake hospital rise years. https://www.bhf.org.uk/what-we-do/news-from-the-bhf/news-archive/2019/november/heart-failure-hospital-admissions-rise-by-a-third-in-five-years. 01/01/2020. Blumchen Jette K. (1990). equivalents (METS) testing . Clinical 13 p.555-565. Bridges Coats Dalal H. Davies Long Mordi I. Rees Sagar V. Singh Exercise-based failure. https://www.cochrane.org/CD003331/VASC_exercise-based-cardiac-rehabilitation-heart-failure. 28th Jan Foundation. https://www.bhf.org.uk/informationsupport/support/practical-support/cardiac-rehabilitation. 29th March Foundation National Audit Report. UK: p32-42. Buys Jayasinghe (2014). Effects community-based meditative Tai Chi improving life heart-failure participants. Aging Mental Health. 18 (3) p.289-295. Ciani Pieplo Walker F. failure: EXTRAMATCH II individual participant meta-analysis. Technology Assessment. 23 (25) p.1-98. Cohn Kubo T. (1993). Validity minnesota living therapeutic enalapril placebo. 71 (12) p.1106-1107. Cowie Gallagher Assessing health?related attending outpatient clinic: pragmatic approach. ESC 6 (1) p.3-9. Eaton Kolbe P. (2005). COOP Charts: simple reliable responsive tool obstructive disease.. Research. 14 p.575-585. Finn Granger Kenchaiah McMurray Michelson Pfeffer Pocock Skali Swedberg Yusuf Zornoff L. Chronic 116 p627-636. Fishman Kinasewitz (1982). Oxygen utilization ventilation 65 p1213-23. Gerogianni Thomai E Assessment outpatients. Archives sciences. Atherosclerotic diseases 4 e38–e46. https://doi.org/10.5114/amsad.2019.84444 Gongora N. chemotherapy-related cardiomyopathy: Can difference?. BBA Clinical. p.69-75. Hanson (1994). failure.. Science Exercise. 26 (5) p.527-537. (2011). Psychosomatic aspects Nothing depression? Herz. p.135-140. Institute https://www.ncbi.nlm.nih.gov/books/NBK481485/. 12th Kolominsky-Rabas Kriza Lesyuk Cost-of-illness studies systematic review 2004-2016. BMC Disorders. p.74. Lainchbury M. (2002). EXERCISE TESTING IN THE ASSESSMENT OF CHRONIC CONGESTIVE HEART FAILURE. Heart. 88 p.583-543. Li F. Zhang resting coronary stroke non-cardiovascular disease: Canadian Medical Journal. 188 (15) p.384-392. Mayo Clinic. Treatment. https://www.mayoclinic.org/diseases-conditions/heart-failure/diagnosis-treatment/drc-20373148. NHLBI. https://www.nhlbi.nih.gov/health-topics/cardiac-rehabilitation. 16th Van E. Exercise: Uncovering Questions Slowly Progressing Towards Truths. http://www.acsm.org/all-blog-posts/acsm-blog/acsm-blog/2019/02/13/heart-failure-exercise. December 2019. Review follows later Games-Howell statistical Angina CHD STEMI remaining categories findings Appendix 1 Comparisons Fig postAx appear legitimate Figure: Normal apart 71-75 category. using Statistically Levene Statistic meaning p<0.05 Non Parametric non Sample small 3 omitted determines : Analysing Total Fitness Lite Hope Once Chart No statistically Difference p>0.05 Bivariate Correlation Generally inverse Pre-Post-Ax lag pressure. anxiety Improvement. Need Pre-post patients conditions? export manually (zobs) http://www.mnestudies.com/research/pearson-correlation-coefficient-between-groups Doing see designed condition. See r-values Is normally distributed? Check Use flow chart ascertain right Choose Proof condition? Compare pre-post MET HADS vertical bar line Calculate MET/QOL/etc Questioning why? mean trough (whisker box plot) “” “”MET skewed men vs women? Do HF? Average length pre-postAX date locations Programmes positives CR? tables Correlations Angina highlighted (* p<0.05 ** p<0.01) Arrhythmia CHD Unstable p<0.01). Insufficient analyse correlations. Treatment relationships measurement Furthermore like-for-like stastically correlation Pre-Post-AX time longer (Pre-Post_AX_Lag) POSITIVE Pressure. Pressure regardless increase/ decrease. others decreased. Medication changes? Some DBP<50mmHg <86mmHg. https://www.mdedge.com/familymedicine/article/65510/cardiology/does-lowering-diastolic-bp-less-90-mm-hg-decrease others. Mean inc correlations correct KW Computed existing data: measures pre_AX_FET Recode string late (Gender Diagnosis) automatic recode XX continuous) (categorical) histogram: Shapira Wilk. p=<0.05 parametric. Accounted large slightest norm will p value. xx Skewness Filtered Removed and/or available removal grip Descriptives 160 population shapiro wilk Ranked kruskall wallis distributed I intend Kurskall Wallis instead (assumes data). assumes needs tested sure respective aggregate function. Absolute compute variable variance. p=0.04 f=2.091. one-way lie re-assesed Question: assessment? categories? Grouped ages year intervals 38-90 Ascertain distributed Confirm (Kruskal-Wallis) confirms confirm completed lapsed assessment strengths R-values transformed Fisher Transformation z-values Significance Z-score comparison: did relatively better/ strongest value z-score tells you how away mean. If equal 0 raw higher average. example +1 above Post-Hoc NEED NOW TO DO EFFECT SIZES BETWEEN GROUPS https://www.youtube.com/watch?v=Sloy2lbtPVc