Plain language summary
Heart failure characterised by reduced ejection fraction (HFrEF) is a condition where the heart muscle does not pump blood as well as it should. Physical activity (PA) and exercise are fundamental in managing HFrEF, with potential benefits in improving functional capacity and quality of life and enhancing prognosis. The aim of this study was to determine if a 6-month lifestyle walking intervention, which includes self-monitoring and regular telephone counselling, could improve the functional capacity of patients with stable HFrEF, as assessed by the 6-minute walk test (6MWT). This study was a multicentre, parallel-group randomised controlled trial conducted across six cardiovascular centers in the Czech Republic. Results showed that the walking intervention, which combined self-monitoring with an activity tracker and telephone counselling, increased the daily step count in patients by approximately 25%. However, the intensity of the walking intervention may not have been sufficient to elicit improvements in their functional capacity as measured by the 6MWT. Authors concluded that while the walking intervention successfully increased physical activity levels in patients with HFrEF, its impact on functional capacity requires further investigation. Thus, the findings of this study underscore the importance of integrating physical activity into the daily lives of patients with HFrEF and suggests that even low-intensity interventions can be beneficial.
Expert Review
Conflicts of interest:
None
Take Home Message:
Increasing physical activity in the form of walking from a lifestyle perspective did not effect functional outcomes of HFrEF.
Evidence Category:
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X
A: Meta-analyses, position-stands, randomized-controlled trials (RCTs)
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B: Systematic reviews including RCTs of limited number
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C: Non-randomized trials, observational studies, narrative reviews
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D: Case-reports, evidence-based clinical findings
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E: Opinion piece, other
Summary Review:
Introduction
- Heart failure with reduced ejection fraction (HFrEF) can be life limiting.
- Whilst structured cardiac programmes are of benefit, limitations such as accessibility and time constraints affect adherence.
- Lifestyle physical activity is an alternative approach to increase activity levels integrated into daily life (e.g. walking).
- This study aimed to determine whether a lifestyle walking intervention could improve functional capacity in individuals with HRrEF.
Methods
- This was a 6-month randomised control trial of adults with stable HFrEF (left ventricular ejection fraction < 40%).
- 202 Individuals were randomised to one of two groups: either physical activity (PA (n=101), which included behaviour change techniques to encourage daily walking; or control, which included usual care and education about the health benefits of exercise.
- The primary outcome was the number of metres walked during the 6 months between groups.
- Secondary outcomes were average daily step count, minutes of moderate and vigorous PA, and measures of N-terminal pro-B-type natriuretic peptide, high sensitivity C-reactive protein, left ventricular ejection fraction, patient reported outcomes, anthropometric measures and Meta-Analysis Global Group in Chronic Heart Failure risk score.
Results
- No differences were observed between the two groups in the primary outcome (mean 7.4 meters [95% CI, -8.0 to 22.7]; P=0.345, n=186).
- However, the PA group did increase their physical activity by 25%.
- Daily step count (+1420 [95% CI, 749 to 2091] significance not given) and amount of moderate to vigorous daily exercise over the control group (+8.2 minutes [95% CI, 3.0 to 13.3] significance not given).
- No differences were seen between the two groups in any of the other secondary outcomes.
Conclusion
- It was concluded that although the lifestyle intervention increased participation in daily physical activity, this did not translate into functional benefits.
Clinical practice applications:
- Walking is considered a practical way to increase physical activity in individuals with HFrEF.
- Consideration is needed to which practical exercise may have more pertinent functional/clinical benefits.
Considerations for future research:
- Understanding is needed on whether it is simply walking that has no effect on HFrEF.
- Other forms of accessible exercise should be assessed for functional outcomes. For example, home based strength and conditioning exercises may produce different results.
Abstract
BACKGROUND Physical activity is pivotal in managing heart failure with reduced ejection fraction, and walking integrated into daily life is an especially suitable form of physical activity. This study aimed to determine whether a 6-month lifestyle walking intervention combining self-monitoring and regular telephone counseling improves functional capacity assessed by the 6-minute walk test (6MWT) in patients with stable heart failure with reduced ejection fraction compared with usual care. METHODS The WATCHFUL trial (Pedometer-Based Walking Intervention in Patients With Chronic Heart Failure With Reduced Ejection Fraction) was a 6-month multicenter, parallel-group randomized controlled trial recruiting patients with heart failure with reduced ejection fraction from 6 cardiovascular centers in the Czech Republic. Eligible participants were ≥18 years of age, had left ventricular ejection fraction <40%, and had New York Heart Association class II or III symptoms on guidelines-recommended medication. Individuals exceeding 450 meters on the baseline 6MWT were excluded. Patients in the intervention group were equipped with a Garmin vívofit activity tracker and received monthly telephone counseling from research nurses who encouraged them to use behavior change techniques such as self-monitoring, goal-setting, and action planning to increase their daily step count. The patients in the control group continued usual care. The primary outcome was the between-group difference in the distance walked during the 6MWT at 6 months. Secondary outcomes included daily step count and minutes of moderate to vigorous physical activity as measured by the hip-worn Actigraph wGT3X-BT accelerometer, NT-proBNP (N-terminal pro-B-type natriuretic peptide) and high-sensitivity C-reactive protein biomarkers, ejection fraction, anthropometric measures, depression score, self-efficacy, quality of life, and survival risk score. The primary analysis was conducted by intention to treat. RESULTS Of 218 screened patients, 202 were randomized (mean age, 65 years; 22.8% female; 90.6% New York Heart Association class II; median left ventricular ejection fraction, 32.5%; median 6MWT, 385 meters; average 5071 steps/day; average 10.9 minutes of moderate to vigorous physical activity per day). At 6 months, no between-group differences were detected in the 6MWT (mean 7.4 meters [95% CI, -8.0 to 22.7]; P=0.345, n=186). The intervention group increased their average daily step count by 1420 (95% CI, 749 to 2091) and daily minutes of moderate to vigorous physical activity by 8.2 (95% CI, 3.0 to 13.3) over the control group. No between-group differences were detected for any other secondary outcomes. CONCLUSIONS Whereas the lifestyle intervention in patients with heart failure with reduced ejection fraction improved daily steps by about 25%, it failed to demonstrate a corresponding improvement in functional capacity. Further research is needed to understand the lack of association between increased physical activity and functional outcomes. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03041610.
Methodological quality
Jadad score
:
3
Allocation concealment
:
Yes
