ardiologists Occupational Therapist Dr Mohd Rahal Yusoff Pusat.pptx

CR reduces all-cause and HF hospitalisations, resulting in lower healthcare costs and a better health-related quality of life (HRQoL) for patients.9 • Most of the evidence for CR has been reported in patients with heart failure with reduced ejection fraction (HFrEF) • In this group of patients, reduced hospitalisations and improved HRQoL were consistently observed across multiple categories such as:10 o age, sex and ethnicity o ischaemic aetiology o New York Heart Association (NYHA) functional class and baseline exercise capacity o ejection fraction (EF) • Mortality benefit was observed during longer follow-up of patients with HFrEF11-13 Exercise training for patients with HF has a favourable safety profile with a low incidence of fatality reported.14 In addition, there was no difference in major cardiac events between patients prescribed exercise training and those who were not.15 However, proper selection of patients remains important (see Section 4: Exercise capacity and functional evaluation). • Patients with an average left ventricular ejection fraction (LVEF) of 25% who participated in the programme experienced cardiac events like worsening HF, hypotension, and arrhythmias, causing approximately 5% of them to withdraw and 8% to be temporarily suspended from the programme.16 • Predictors of cardiac events during HF rehabilitation include baseline:16 o left ventricular enlargement (left ventricular end diastolic diameter >65 mm) o high natriuretic peptide levels o poor exercise capacity o increased ventilation during exercise o post-pacemaker or intracardiac defibrillator implantation To date, small trials have demonstrated that exercise training among patients with heart failure with preserved ejection fraction (HFpEF) significantly improved the following: 17 • diastolic function index • LVEF • peak oxygen intake (VO2 peak ) • 6-minute walking distance (6MWD) test • ventilatory threshold Recognising the evidence gap for patients with HFpEF, several international societies are prioritising the need for appropriately powered randomised trials to assess the efficacy and safety of CR in HFpEF and heart failure with mildly reduced ejection fraction (HRmrEF) patients.11

1. ardiologists Occupational Therapist Dr Mohd Rahal Yusoff Pusat Pakar Perubatan , Universiti Teknologi Mara ( UiTM ) Dr Gurudevan Mahadevan Hospital Sultanah Aminah Dr Koh Hui Beng , Randy Institut Jantung Negara Dr Raja Ezman Raja Faridz Bin Raja Shariff Pusat Pakar Perubatan , Universiti Teknologi Mara ( UiTM ) Rehabilitation Physicians Associate Professor Dr Anwar Suhaimi Pusat Perubatan Universiti Malaya Dr Leong Be Kim Pusat Jantung Sarawak Dr Wan Najwa Wan Mohd Zohdi Pusat Pakar Perubatan , Universiti Teknologi Mara ( UiTM )

2. Cardiologists Rehabilitation Physicians Dr Alan Fong Yean Yip Pusat Jantung Sarawak Dr David Chew Soon Ping Cardiac Vascular Sentral Kuala Lumpur (CVSKL) Dr Lydia Abdul Latif ReGen Rehab Hospital Dr Farhah Amalina Muhammad Ehsan Hospital Sultan Idris Shah Dr David Quek Kwang Leng Pantai Hospital Kuala Lumpur Dr Jeyamalar Rajadurai Subang Jaya Medical Centre Dr Mohamed Jahangir Abdul Wahab Hospital Pulau Pinang Dr Muhamad Ali SK Abdul Kader Hospital Sultan Idris Shah Dr Ong Mei Lin Gleneagles Hospital Penang Dr Razali Omar Cardiac Vascular Sentral Kuala Lumpur (CVSKL) Dr Wan Azman Wan Ahmad Pusat Perubatan Universiti Malaya

3. Statement of intent The Consensus Statement on Cardiac Rehabilitation for Patients Living with Heart Failure is meant to provide guidance for the evidence-based clinical management of heart failure rehabilitation. It is based on the best available evidence at the time of the consensus development. Adherence to the consensus may not necessarily guarantee the best outcome in every case. Every healthcare provider is responsible for the management of their unique patient based on the clinical presentation and the management options available. Every care has been taken to ensure that the information is correct at the time of publication. However, in the event of errors or omissions, corrections will be published in the web version of this document, which will always serve as the definitive version.

4. Consensus development The consensus development group consisted of cardiologists, rehabilitation physicians, a dietician, and an occupational therapist. A literature search was carried out using the following electronic databases: PubMed , Medline, and Cochrane Databases of Systemic Reviews. In addition, the reference lists of all relevant articles were searched to identify further studies. Reference was also made to the latest edition of other guidelines on heart failure rehabilitation available during the development of the document. The consensus statements were formulated with agreement by the development group members. Where the evidence was insufficient, a consensus was reached by the group members. The draft consensus was submitted for external review by experts in cardiology and heart failure rehabilitation.

5. Objectives The aim of this consensus is to provide evidence-based recommendations to assist healthcare providers providing rehabilitation services to patients with heart failure. Target population This consensus is applicable to all patients with a diagnosis of heart failure. Target audience This consensus is meant for all healthcare professionals involved in managing patients with heart failure, which includes cardiologists, rehabilitation physicians, internal medicine physicians, physiotherapists, dietitians, nurse educators, pharmacists, heart failure specialist nurses, exercise therapists, and also for patients.

6. 1.1 Cardiac rehabilitation in general The World Health Organization (WHO) definition of cardiac rehabilitation (CR) is “The sum of activities required to influence favourably the underlying cause of the disease, as well as to provide the best possible physical, mental and social conditions, so that the patients may, by their own efforts, preserve or resume when lost as normal a place as possible in the community”.1 The current practice of CR utilises a multicomponent approach that allows the patient to selfmanage their long-term condition. This approach includes: 2,3 • patient assessment • patient education • risk factor modification • dietary recommendations • counselling (smoking cessation and psychological) • overcoming the barriers to managing their chronic disease Despite numerous guideline recommendations, the enrolment rate for CR is low, especially among elderly patients. 4,5 1.2 Cardiac rehabilitation for heart failure CR targeting patients with heart failure (HF) aims to: 2,3 • improve patients’ exercise capacity and quality of life • improve their knowledge of disease management by educating them about the importance of guideline directed medical therapy (GDMT) and treatment adherence • re-enforce non-pharmacological management strategies • advocate for a healthy lifestyle • teach coping strategies for adapting activities of daily living to mild clinical parameter f luctuations (like lower heart rate and blood pressure) • reduce hospitalisation and mortality Fatigue and breathlessness are the two primary symptoms that cause individuals to limit their physical activity to prevent or alleviate symptoms. In turn, this could lead to deconditioning , which can present with reduced physical, mental, and cognitive capacity. Hence, this will relate closely to HF complications, increasing morbidity and recurrent admissions. However, deconditioning is preventable and potentially treatable with exercise training, which can improve cardiovascular, respiratory, and skeletal muscle function, ultimately enhancing aerobic capacity.

7. Generally, for patients with HF, exercise intervention (or regular physical activity) is recommended, as it is safe and effective for those who are able to participate, for improving their functional status. Exercise intervention: • should only be started in clinically stable patients following medical therapy6 • can be introduced within days before hospital discharge • should be continued during the outpatient phase for patients in remission • can be reintroduced and/or intensified if a new event occurs during the patient’s HF journey (i.e., acute decompensation or worsening of HF) • can be implemented from HF onset up to its terminal stages A multidisciplinary team approach for HF rehabilitation is fundamental. The team should include the following members: • nurse • physiotherapist/exercise therapist • dietitian • rehabilitation physician • pharmacist • HF specialist or a general physician with an interest in cardiology Additional healthcare professionals that can be included are: a psychologist, an occupational therapist, and a social worker, and may include palliative care (see Section 14.3: Frailty and palliative care). Traditionally, HF rehabilitation is a centre-based programme . However, alternative delivery methods such as: home-based, community, digital, or hybrid programmes can be explored, as communications technology is improving in terms of speed, availability and user-friendliness.3 This consensus document on CR with a focus on HF provides guidance for establishing a programme that can benefit patients with HF and ensure a good quality of life and health status for them and their families. The success of these programmes depends on setting achievable goals with the patient and ensuring its sustainability throughout their HF journey.

8. Physiological consequences of heart failure HF results in a complex multisystem impairment that influences morbidity and mortality. The physiological consequences of HF are listed below.¹ Cardiovascular system: • Reduced myocardial performance triggers peripheral vascular constriction in an effort to increase venous return to enhance stroke volume and cardiac output Respiratory system: • Elevated cardiac filling pressures, driven by poor myocardial function and fluid overload, contribute to the development of pulmonary oedema Renal system: • Poor cardiac output resulting in fluid retention Neurohormonal system: • Over time, heightened sympathetic stimulation leads to the desensitisation of β-1 adregenic receptors, diminishing the cardiac ionotropic response Musculoskeletal (MSK) system: • Inactivity or other chronic diseases result in muscle wasting and possible myopathies and osteoporosis Haematological system: • The reduced oxygen transport, concurrent liver disease (cardiac cirrhosis) or stagnant blood flow within the heart chambers due to poor cardiac contraction may result in polycythaemia , anaemia and haemostatic abnormalities Hepatic system: • Hypoperfusion secondary to an inadequate cardiac output or hepatic venous congestion may result in cardiac cirrhosis Pancreatic system: • The impact of inadequate cardiac output and the resulting hypoperfusion may result in impaired insulin secretion and glucose intolerance Nutrition and biochemical system: • Malnutrition and cachexia resulting from anorexia

9. CR is a long-term intervention, designed as a comprehensive programme involving a multidisciplinary team that can be offered to patients with HF.1 A CR programme for HF comprises general CR and HF focused strategies (Table 3-1). Table 3-1. Strategies for CR General CR strategies Optimal exercise training Nutrition counselling Managing comorbidities Smoking cessation Psychological support Counselling about physical activity HF specific CR strategies Ventricular function and arrhythmia risk assessment Functional capacity assessment Volume status assessment Monitoring GDMT side effects Health behaviour change Education Exercise training is a fundamental component of CR. 2 • It is recommended as a Class I indication for patients with HF by international guidelines3,4 and the 2023 Malaysian Clinical Practice Guidelines for the Management of Heart Failure5 • Over the past decade, several meta-analyses have reported the benefits of CR for several cardiac conditions, including HF6-8

10. CR reduces all-cause and HF hospitalisations , resulting in lower healthcare costs and a better health-related quality of life ( HRQoL ) for patients.9 • Most of the evidence for CR has been reported in patients with heart failure with reduced ejection fraction ( HFrEF ) • In this group of patients, reduced hospitalisations and improved HRQoL were consistently observed across multiple categories such as:10 o age, sex and ethnicity o ischaemic aetiology o New York Heart Association (NYHA) functional class and baseline exercise capacity o ejection fraction (EF) • Mortality benefit was observed during longer follow-up of patients with HFrEF11-13 Exercise training for patients with HF has a favourable safety profile with a low incidence of fatality reported.14 In addition, there was no difference in major cardiac events between patients prescribed exercise training and those who were not.15 However, proper selection of patients remains important (see Section 4: Exercise capacity and functional evaluation). • Patients with an average left ventricular ejection fraction (LVEF) of 25% who participated in the programme experienced cardiac events like worsening HF, hypotension, and arrhythmias, causing approximately 5% of them to withdraw and 8% to be temporarily suspended from the programme.16 • Predictors of cardiac events during HF rehabilitation include baseline:16 o left ventricular enlargement (left ventricular end diastolic diameter >65 mm) o high natriuretic peptide levels o poor exercise capacity o increased ventilation during exercise o post-pacemaker or intracardiac defibrillator implantation To date, small trials have demonstrated that exercise training among patients with heart failure with preserved ejection fraction ( HFpEF ) significantly improved the following: 17 • diastolic function index • LVEF • peak oxygen intake (VO2 peak ) • 6-minute walking distance (6MWD) test • ventilatory threshold Recognising the evidence gap for patients with HFpEF , several international societies are prioritising the need for appropriately powered randomised trials to assess the efficacy and safety of CR in HFpEF and heart failure with mildly reduced ejection fraction ( HRmrEF ) patients.11