HEART FAILURE

PMR4GP
Kevin Triangto, SpKFR
National Cardiovascular Center Harapan Kita
“Heart disease has remained the leading
cause of death at the global level for the
last 20 years.”

“People are living longer – but with more

disability”
—WHO 2000-2019 Global Report
INTRODUCTION
 LEARNING OBJECTIVES

Diagnostics Management Further Readings

Important aspects of Cardiac Rehabilitation in a Stay put, free resources
diagnosis glance ahead
01. DIAGNOSIS
Exfoliating heart failure inside-out
 HF SPECIFIC EPIDEMIOLOGY

12% 1-2% 1st

increase adults Rank

INCIDENCE PREVALENCE HOSPITALIZATION

due to an increase in Classified as a global cause as compared to
aging population pandemic since 2014 other CV diseases

Groenewegen A, Rutten FH, Mosterd A, Hoes AW. Epidemiology of heart failure. European journal of heart failure. 2020 Aug;22(8):1342-56.
World Heart Federation fact sheet on Heart Failure. Available online: https://world-heart-federation.org/resource/heart-failure-infographic/
McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by the Task Force for the diagnosis and
treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure Association (HFA) of the ESC. European heart journal. 2021 Sep 21;42(36):3599-
726.
 IN ASIA:

SIMILAR
PROPORTION OF
NYHA II TO NYHA III/IV
Savarese G, Lund LH. Global public health burden of heart
failure. Cardiac failure review. 2017 Apr;3(1):7.
 COMMON ETIOLOGIES

Myocardial Infarctions Valvular Diseases Hypertension

Cardiomyopathies Arrhythmias Infective Myocarditis

Tsutsui H, Isobe M, Ito H, Okumura K, Ono M, Kitakaze M, Kinugawa K, Kihara Y, Goto Y, Komuro I, Saiki Y. JCS 2017/JHFS 2017 guideline on diagnosis and
treatment of acute and chronic heart failure digest version. Circulation Journal. 2019 Sep 25;83(10):2084-184.
 MEDICAL DIAGNOSIS
Framingham Criteria

Groenewegen A, Rutten FH, Mosterd A, Hoes AW. Epidemiology of heart failure. European journal of heart
failure. 2020 Aug;22(8):1342-56.
Mahmood SS, Wang TJ. The epidemiology of congestive heart failure: the Framingham Heart Study
perspective. Global heart. 2013 Mar 1;8(1):77.
 HF TYPES PROGRESSION

HFrEF, HFmrEF, HFpEF

Symptoms ± Signs, change in
LVEF rEF ≤40%, mrEF 41-
49%, pEF ≥50%

Additional for HFpEF

Objective evidence of
structural and/or functional
abnormalities, consistent with
presence of LV diastolic
dysfunction

Tsutsui H, Isobe M, Ito H, Okumura K, Ono M, Kitakaze M, Kinugawa K, Kihara Y, Goto Y, Komuro I, Saiki Y. JCS 2017/JHFS 2017 guideline on diagnosis and treatment
of acute and chronic heart failure digest version. Circulation Journal. 2019 Sep 25;83(10):2084-184.
 MEDICAL DIAGNOSIS

Tsutsui H, Isobe M, Ito H, Okumura K, Ono M, Kitakaze M, Kinugawa K, Kihara Y, Goto Y, Komuro I, Saiki Y. JCS 2017/JHFS 2017 guideline on diagnosis and
treatment of acute and chronic heart failure digest version. Circulation Journal. 2019 Sep 25;83(10):2084-184.
 ROLES FOR GP AND PMR SPECIALIST?
● Routine HF Symptom Checker
● Compliance measurement and
family education
● Peak flow meter
● Short Physical Performance
Battery
● Six-minute walk test (6MWT)
● High-risk patients exercise testing
and prescription
● Comprehensive functional
assessments
● Maximal Exercise Testing –
Cardiopulmonary Exercise Test
(CPET) (PMR Consultant)
● USG assessments – Peripheral
muscles and diaphragm
● Program evaluation and
rehabilitation targets
 Short Physical
Performance
Battery (SPPB)
Could be tested when patient has:
•Good Cognitive Function
•Independently Walking
•Good Sitting Balance

Assist your patient and observe

vital sign changes at every test

Martín-Sánchez FJ, Christ M, Miró Ò, Peacock WF, McMurray JJ, Bueno H, et al.
Practical approach on frail older patients attended for acute heart failure.
International journal of cardiology. 2016 Nov 1;222:62-71.
 FRAILTY (Fried Scale)

Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Frailty in Older Adults: Evidence for a Phenotype. The Journals of Gerontology Series
A: Biological Sciences and Medical Sciences. 2001 Mar 1;56(3):M146–57.
 FRAILTY (FRAIL Questionnaire)

Nozaki K, Kamiya K, Hamazaki N, Saito H, Saito K, Ogasahara Y, et al. Validity and Utility of the Questionnaire-based FRAIL Scale in Older Patients with Heart Failure:
Findings from the FRAGILE-HF. Journal of the American Medical Directors Association. 2021 Aug 1;22(8):1621-1626.e2.
02. MANAGEMENT
Tailor-made therapy towards the ultimate goal of
transforming the patient into an individual with a
better functional capacity
 OVERVIEW OF CARDIAC REHAB

2ndary Prevention Lifestyle

Consult cardiologist for Improve diet, reduce stress,
comorbidity control & HF alcohol consumption and
medications smoking cessation

Exercise Routine Checks

Part of the daily routines Enforce patients to have
aside from medications self awareness & access
to healthcare

Pescatello LS. Exercise prescription for patients with cardiovascular and cerebrovascular disease. In: Pescatello LS, Arena R, Riebe D, Thompson PD, editors. ACSM's
Guideline for Exercise Testing and Prescription, 9th edn. Baltimore, MD: Wolters Kluwers Lippincott Williams & Wilkins; 2014. p. 236–59.
 EXERCISE FOR HEART FAILURE

Physical Activity
Physical activity is defined as any bodily
movement produced by skeletal muscles that
results in energy expenditure.

Exercise
Exercise is a subset of physical activity that is
planned, structured, and repetitive and has
a final or an intermediate objective.

McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: Developed by
the Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC) With the special contribution of the Heart Failure
Association (HFA) of the ESC. European heart journal. 2021 Sep 21;42(36):3599-726.
Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public health reports. 1985
Mar;100(2):126.
 EXERCISE PRESCRIPTION IN STABLE HF

Pescatello LS. Exercise prescription for patients with cardiovascular and cerebrovascular disease. In: Pescatello LS, Arena R, Riebe D, Thompson PD, editors. ACSM's Guideline for Exercise Testing
and Prescription, 9th edn. Baltimore, MD: Wolters Kluwers Lippincott Williams & Wilkins; 2014. p. 236–59.
Laoutaris ID, Piotrowicz E, Kallistratos MS, Dritsas A, Dimaki N, Miliopoulos D, et al. Combined aerobic/resistance/inspiratory muscle training as the ‘optimum’exercise programme for patients
with chronic heart failure: ARISTOS-HF randomized clinical trial. European Journal of Preventive Cardiology. 2021 Dec;28(15):1626-35.
PRO TIP FOR EXERCISE IN HF

Talk Test Handgrip

Able to talk during exercise, Best dumbbells should
unable to follow pitch while accommodate full
singing handgrip

Single Breath Count Consult to PMR

Test
Useful to rapidly assess Advanced exercise
improvement, safer than testing, progression, and
breath holding rehab targets
Suggested ICF Core Set of Heart Failure
Shiota S, Naka M, Kitagawa T, Hidaka T, Mio N, Kanai K, et al. Selection of Comprehensive Assessment Categories Based on the International Classification of Functioning, Disability, and Health for Elderly Patients with Heart Failure: A Delphi
Survey among Registered Instructors of Cardiac Rehabilitation. Occupational Therapy International. 2021 Jun 28;2021.
03. FURTHER READINGS
Free stuffs, what’s not to like?
DOWNLOADABLE
REFERENCES

BMJ 2015 Cardiac Rehabilitation – Program Basics

● JCS 2012 – Cardiac Rehab Baseline Explanation
● AHA/ACC/HFSA 2022 HF CPG – Latest Evidence
JCS JHFS 2017 – HF Exercise Physiology Explanation
● ESC 2022 Position Statement – Intensity Prescription
● ESC 2020 Secondary Prev. – CV Exercise Prescription
● APSC 2021 Sports – Screening Classification Athletes
Pocket Ref eBook – http://tiny.cc/HF_Mobilize
 100%

MAJOR STUDY
Extreme disability

Severe disability

Moderate disability

Mild disability

No problem
0%
UAC GAR SCA GAP LAC PSO GLOBAL
KEY MESSAGES (Modified) Figure 1. Prevalence of ICF disability categories in different domains. X axis: domains
of WHODAS 2.0 (UAC, understanding and communicating; GAR, getting around; SCA, self-care;
● HF causes disability and deterioration in the GAP, getting along with people; LAC, life activities; PSO, participation in society). Y axis: rate of
people in each disability level.
quality of life.
● Gender and clinical situation are important
predictors of such disability.
● GPs have an ideal position to mobilize health and social resources.

García-Olmos L, Batlle M, Aguilar R, Porro C, Carmona M, Alberquilla A, Sánchez-Gómez LM, Monge E, López-Rodríguez AB, Benito L, Baños N. Disability and
quality of life in heart failure patients: a cross-sectional study. Family Practice. 2019 Dec;36(6):693-8.
CONCLUSIONS

“Multidisciplinary approaches towards HF won’t

be as complex if YOU know what your role
(power) is” – Triangto K (2022)

● HF is an important etiology of disability as shown by WHO

● Increasing prevalence with ageing population, progressive after CV event
● Affects body structure, function, activity, participation, with several barriers
● Treatment requires multidisciplinary approaches
● Essential aspects of therapy involves early education and rehabilitation
 “with great
POWER…”
– Parker B (1972)
 THANK YOU

You may direct queries to: kevintriangto14@gmail.com