Building a Successful Exercise Training Program for HF Patients

Getting patients to exercise is a challenge for any healthcare professional, but for those treating heart failure (HF) patients, physical fitness can be a particularly tough sell, according to Ileana L. Pina, MD, of Case Western University, Cleveland, OH.

Presenting in a session entitled, “Patient Education: Strategies that Work,” Tuesday at the HFSA 14th Annual Scientific Sessions, Pina spoke about the fine line that clinicians must walk in helping patients develop an exercise regimen following a cardiovascular event. Clinicians need to assess the level of activity that they believe the patient is capable of (which may be in contrast to what the patient believes), make sure patients are getting the proper amount and type of exercise, and ensure that it becomes part of the patient’s lifestyle.

“It’s not easy,” said Pina. In fact, she suggested that convincing patients to exercise can be even more difficult than getting them to take medications.

But it doesn’t have to be that way, she said, adding that both healthcare professionals and patients can benefit from an exercise plan that progresses slowly and adapts to the patient’s capabilities. Generally, Pina noted, the goals with HF patients are to stabilize symptoms, conserve energy by pulling rather than pushing and working at the waist level, establish a daily work-out schedule, avoid extreme temperatures, and avoid physical activity shortly after meals.

All of this starts by assessing the patient’s level of function, which can be tricky, as patients often either under- or over-estimate their levels of strength and endurance. One of the methods clinicians can use to determine a patient’s physical function is to have him or her walk on a treadmill with a briefcase—which offers a way to mimic work activity, or lift heavy objects (as it may be required by his or her job). When developing a plan, cardiac pulmonary exercise should be considered the gold standard, she said.

Before clearing a patient to return to work following a HF diagnosis, clinicians should administer a mental health questionnaire, make sure patients consider all financial and health insurance issues, and if necessary, have them undergo an exercise test. When developing an exercise program for a patient, Pina advised physicians to recommend recreational activities that are enjoyable for the patient; be sure to stress the importance of warm-up and cool-down; emphasize that the more intense the workout, the shorter the duration needed; tell patients to avoid working out in intense temperatures and right after meals; and remind patients that they should stop exercising if symptoms occur.

She also recommends using the Borg Scale of Perceived Exertion to make sure that patients are continuously increasing their level of activity as they continue to recover.

In another presentation, Nancy Houston-Miller, RN, Stanford University School of Medicine, Stanford, CA, addressed the issues of adherence in health literacy in disease management.

According to Houston-Miller, 93 million Americans have basic or lower than basic literacy skills, which results in $73 million in hospital stays and readmissions.

Low literacy—which has found to be associated with decreased knowledge of medical conditions, poor medication recall, nonadherence to treatment recommendations, and poor mental and phys outcomes—is prevalent in anywhere from one-third to half of all HF patients, she estimated. One of the most common areas of nonadherence involves taking medications, which can be difficult for patients who can’t understand or read labels.

To that end, Houston-Miller has identified the following steps to help improve literacy adherence in the clinical practice:

• Simplify the drug regimen
• Offer information in two formats: written and video
• Inform patients about who to call and when if side effects present, and sex expectations about transient side effects
• Communicate about the need for medication to help reduce hospitalization
• Use a pill chart, and review instructions using the repeat-back method of recall
• Have patients demonstrate how they will take the medication and read the label
• Observe medication-taking during the first month
• Stress the importance of maintaining therapy, even if patients feel fine
• Make sure patients can afford to pay for medications
• Make a plan for refills (include a follow-up phone call if necessary
• Ask patients to “brown bag” all of their medications
• Try to determine adherence by asking questions like, “How many doses have you missed in the last seven days?”
• Use photos when necessary, and prepare all written materials on a 6th grade reading level

“We now know that health literacy correlates with medication adherence and importance healthcare outcomes,” said Houston-Miller. It is critical, therefore, that clinicians screen individuals for health literacy and ensure that their knowledge of medications and self-treatment is sufficient.