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Should we think more about implementing novel technologies in home based cardiac rehabilitation?

comment by Stefan Busnatu, EAPC Young Ambassador Romania

Cardiovascular Rehabilitation

Home-based cardiac rehabilitation programmes can increase access and have been shown to be as effective as group- or hospital-based cardiac rehabilitation, after myocardial infarction and coronary revascularization, implying similar costs. [1] The high financial burden produced by the heart failure on the medical system is well documented, [2] but little evidence is available on the clinical and cost-effectiveness of home-based cardiac rehabilitation in heart failure. [3]

In a very recently published research, Dalal et al. [4] performed a multicenter randomized trial to compare the REACH-HF (Rehabilitation EnAblement in CHronicHeart Failure) intervention, a facilitated self-care and home-based cardiac rehabilitation programme to usual care, for adults with heart failure with reduced ejection fraction (HFrEF).

In the study, 216 participants were randomly allocated to the REACH-HF group (107) and control group (109). Participants were predominantly men (78%), with an average age of 70 years and mean left ventricular ejection fraction of 34%. According to the English authors, in the UK most patients with heart failure do not undertake cardiac rehabilitation, a situation that is frequently encountered throughout Europe. [5], [6] The usual care in this trial was a no cardiac rehabilitation approach, that included medical management according to national and local guidelines, including specialized heart failure nurses. Both, REACH-HF and control groups received this usual care. The REACH-HF intervention was an evidence informed, patient-centered, self-care support programme, based on 4 pillars:

  1. a home based exercise manual for patients
  2. a ‘Progress Tracker’ booklet
  3. a caregivers manual
  4. specialized training for the involved medical personnel.

The intervention was delivered at the patient’s home via a mixture of face-to-face and telephone contacts over 12 weeks. The study’s primary hypothesis was that the addition of the REACH-HF intervention to usual care would improve disease-specific HRQoL (Minnesota Living with Heart Failure questionnaire (MLHFQ)) at 12 months compared with usual care alone. Secondary outcomes were death, hospitalization, generic quality of life, psychological wellbeing, exercise capacity and physical activity.
At 12 months, MLHFQ total scores improved in the REACH-HF group, but did not change in the control group, with a significant between-group difference of – 5.7 points (95% CI –10.6 to –0.7) in favor of the REACH-HF group (p<0.025); Results for the secondary outcomes had no statistical significance at 12 months. Overall, there were 33 admissions (four related to heart failure) in the REACH-HF group and 35 (10 related to heart failure) in the control group.

To calculate costs, caregiver contact sheets were completed at 12 months and were available for 94 (98%) participants in the REACH-HF intervention group. Taking into account the contact times, that on overall was 8.25 h per participant, the training, travel and consumables used by the caregiver, the mean total cost was estimated to 418.39 pounds.

Although the study has some limitations (lack of blinding, some missing data and the adherence levels of the participants) it proves that assisted homebased cardiac rehabilitation intervention is associated with a better quality of life, better patient ratings of self-care maintenance assessed using the Self-Care of Heart Failure Index, indicating enhanced engagement in activities such as monitoring their weight and increased exercise, looking for signs of fluid retention and using a system to help remember daily drugs.

Through its results, this study supports the hypothesis that by the use of novel technologies, based on artificial intelligence, machine learning strategies and wearables health monitoring solutions, we might be able to assist heart failure patients using intelligent virtual coaches during their rehabilitation, at lower costs, with a possible better adherence and outcomes [7].

Note: The content of this article reflects the personal opinion of the author and is not necessarily the official position of the European Society of Cardiology. 


Stefan Busnatu commented on this article:

[4] H. M. Dalal et al., “The effects and costs of home-based rehabilitation for heart failure with reduced ejection fraction: The REACH-HF multicentre randomized controlled trial,” European Journal of Preventive Cardiology, p. 204748731880635, Oct. 2018 

Additional References:


[1] Dalal HM, Zawada A, Jolly K, et al. Home based versus centre based cardiac rehabilitation: Cochrane systematic review and meta-analysis. BMJ 2010; 340: b5631
[2] Braunwald E. The war against heart failure: The Lancet lecture. Lancet 2015; 385: 812–824.
[3] Taylor RS, Sagar VA, Davies EJ, et al. Exercise-based rehabilitation for heart failure. Cochrane Database Syst Rev 2014; CD003331.
[5] R. Humphrey, M. Guazzi, and J. Niebauer, “Cardiac Rehabilitation in Europe,” Progress in Cardiovascular Diseases, vol. 56, no. 5, pp. 551–556, Mar. 2014.
[6] Golwala H, Pandey A, Ju C, et al. Temporal trends and factors associated with cardiac rehabilitation referral among patients hospitalized with heart failure: Findings from Get with The Guidelines–Heart Failure Registry. J Am Coll Cardiol 2015; 66: 917–926.
[7] Virtual Coaching Activities for Rehabilitation in Elderly H2020 project No 769807