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Hellenic Society of Cardiology (2017) xx, 1e4

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LETTER TO THE EDITOR

The effect of group-based cardiac rehabilitation models on the quality of life

and exercise capacity of patients with chronic heart failure

rehabilitation of patients with heart diseases. The aim of

KEYWORDS
Cardiac rehabilitation;
Quality of life;
Exercise capacity;
Chronic heart failure
1. Introduction
Despite the development of several invasive and pharma-
cological interventions, patients with chronic heart failure
(CHF) suffer from reduced functional capacity and low
quality of life (QoL) because of their inability to perform
activities of daily living (ADL), mainly due to excess dys-
pnea and fatigue.1,2 QoL is a concept that is constructed
with multiple aspects that require interdisciplinary ap-
proaches including medicine, sociology, psychology, eco-
nomics, and philosophy. Wilhelmsen L, et al., referred
that QoL among patients with CHF is crucial as it is a
powerful predictor of mortality and morbidity after hospi-
tal discharge.3 Exercise training encompasses a central
element of CR for patients with CHF because of improve-
ments in functional capacity, cardiac function, and QoL.4,5
The benefits and advantages of group-based high-intensity
aerobic interval training (HIAIT) on functional capacity,
QoL, and cost effectiveness are proven.6 These training
modalities are not limited to the improvement of exercise
capacity of patients with CHF but also depend on their
psychological and emotional status, to encouraging them to
return to work and ADL.1 In the past decade, many studies
have focused on exploring the effects of different training
modalities on patients with CHF. Currently there is a lack of
consensus on the optimal intensity of exercise for the
Peer review under responsibility of Hellenic Society of
Cardiology.
http://dx.doi.org/10.1016/j.hjc.2017.04.003
1109-9666/ª 2017 Hellenic Society of Cardiology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
the present randomized controlled trial was to introduce a
modified group-based HIAIT in a Bulgarian cardiac rehabil-
itation (CR) practice, which we refer as modified Ullevaal
(m-Ullevaal), and to evaluate its impact on the QoL in
Bulgarian patients with CHF. Our study was a pragmatic
pilot feasibility study with a two-arm parallel intervention
design and was conducted at the Medical Center for Sports
Medicine and Rehabilitation, Plovdiv, Bulgaria. All eligible
subjects, after giving their informed consent, were ran-
domized to perform m-Ullevaal or moderate-intensity
continuous training (MICT). The Department of Health
Management and Health Economics at the Medical Univer-
sity of Plovdiv performed the randomization of the subjects
using a block randomization design (by age, sex, NYHA
class, and cause of CHF). To achieve optimal results, each
major CR group was subdivided into 6 subgroups consisting
of 5 to 8 individuals. All assessments were repeated after 1
and 12 weeks of intervention. Investigators were unblinded
to group assignment. Fig. 1 provides details of patient flow
through the study phases. The results presented belong to
75 eligible subjects (age: 64, 28
6, 25 years) with stable
CHF, New York Heart Association classes II to IIIB. The two
training groups did not significantly differ in demographic
characteristics.
We applied the inclusion criteria issued by National
Institute for Health and Care Excellence (NICE).7 The cau-
ses of CHF were ischemic cardiomyopathy (58.7%), hyper-
tensive heart failure (26.7%), and idiopathic dilated
cardiomyopathy (14.7%). The participants were examined
when they were clinically stable, without any changes in
medication during the previous 4 weeks. Thirty-eight
(nZ38) eligible subjects were randomized to perform m-
Ullevaal for a 12-week period. This CR intervention consists
of three high-intensity intervals where participants were
encouraged to achieve HRmax of 90% and two moderate
intensity intervals (HRmax: 70%). During high-intensity in-
tervals of m-Ullevaal, all subjects performed aerobic dance
movements, fast walking, side stepping, strength, endur-
ance, and coordination exercises supervised by the Physical
and Rehabilitation Medicine (PRM) physician.8

Please cite this article in press as: Papathanasiou J, et al., The effect of group-based cardiac rehabilitation models on the quality of life
and exercise capacity of patients with chronic heart failure, Hellenic Society of Cardiology (2017), http://dx.doi.org/10.1016/
j.hjc.2017.04.003
 + MODEL
2 Letter to the Editor

Figure 1 Patient flow diagram. HIAIT m-Ullevaal: high-intensity aerobic interval training; MICT: moderate-intensity continuous
training.

The modified Borg scale9 and beats per minute music the relation between change in QoL (MLHFQ score) and
pieces were used to adjust the exercise intensity of each change in 6MWD. Unless otherwise stated, data are pre-
training interval. Each interval of m-Ullevall CR model sented as mean
standard deviation (SD), with a signifi-
lasted for 5 and 10 min, while the overall duration of the cance level of p <0.001.
session was 40 min. The members of CR team offered 12
consultations to the participants regarding symptom 2. Results
management of CHF, medication issues, and dietary
recommendations.8
The MLHFQ scores significantly improved after 12 weeks of
Thirty-seven (nZ37) subjects of our study were ran-
CR interventions in both exercise groups. However, the
domized to perform MICT on electromagnetically braked
improvement in MLHFQ score was significantly greater in
cycle ergometers (Pure Bike R 4.1, Tunturi, Netherlands).
the m-Ullevaal group than in the MICT group (-17.26% vs.
During each MICT training session, the subjects were
-6.42%, p<0.001). A 10-point difference between groups
encouraged to achieve HRmax of 90%. The functional ca-
in MLHFQ scores was observed after 12 weeks (7- and 3-
pacity was evaluated by the 6-min walk test (6MWT), which
point improvement in the m-Ullevaal and MICT groups,
has been widely used as an effective and necessary tool in
respectively). A significant increase was found in the dis-
modern CR.10 It was performed in a 30-m marked corridor in
tance covered assessed through 6MWT in the m-Ullevaal
the Medical Center for Rehabilitation and Sports Medicine I
and MICT groups (63 m, 14.53% vs. 44 m, 10.6%, respec-
(Plovdiv, Bulgaria). All included subjects were requested
tively, p<0.001). A significant inverse correlation was
to complete the translated Bulgarian version of the Min-
observed between changes in MLHFQ score and changes in
nesota Living with Heart Failure questionnaire (MLHFQ)
6MWTD (rZ0. 35), indicating changes in QoL related to
at baseline (T1) and after 24 training sessions (after 12
improved functional capacity. Detailed results are pre-
weeks; T2).11
sented in Table 1.
The training sessions were supervised by the members of
the CR team (cardiologist, PRM physician, physiotherapist,
and nurse) of the Medical Center for Rehabilitation and 3. Discussion
Sport Medicine I (Plovdiv, Bulgaria).8 Data were analyzed
with Statistical Package SPSS version 17.0 (SPSS Inc., Chi- The improvement in MLHFQ scores achieved in both CR
cago, IL, USA). We used the graphical assessment of groups may be associated with the poor MLHFQ scores at
normality and Kolmogorov-Smirnov (K-S) test. Independent- baseline, which were lower than the MLHFQ scores from
sample t-test and Mann-Whitney U-test were used to eval- other studies with similar design and, consequently, pro-
uate unrelated observations between groups and correla- vide a large gap for further improvement. We speculate
tion analysis (Pearson’s correlation coefficient) to assess that the low scores achieved in MLHFQ by the Bulgarian

Please cite this article in press as: Papathanasiou J, et al., The effect of group-based cardiac rehabilitation models on the quality of life
and exercise capacity of patients with chronic heart failure, Hellenic Society of Cardiology (2017), http://dx.doi.org/10.1016/
j.hjc.2017.04.003
 + MODEL
Letter to the Editor
Table 1 MLHFQ and Functional Capacity (6MWT) in both CR groups before and after CR interventions (mean
SD).
Training Groups HIAIT (m-Ullevaal)
Variable Baseline (T1) Follow up (T2) Difference
T2-T1 (%)
MLHFQ 37.37
6.66 30.92
6.54 - 17.26
3.78 <0.001 38.27
8.44
6MWT (m) 443.2
42.9 506.3
39.3 14.5
4,7
patients with CHF can be associated, on the one hand, with
their poor socioeconomic statusdmost of them are retired
with low pensions and low living standard. This situation is
also worsened by a deepening economic crisis. On the other
hand, they can also be interpreted in relation to the
problems of the healthcare system and its ongoing reforms.
Indicatively, difficulties of organizational and legal level,
health insurance, and others (e.g., high rise in costs of
medication, restricted access to medical specialists, and
lack of national CR programs) are some of the aspects that
deteriorate the dynamics of the Bulgarian healthcare
system.
The 10 -point difference in MLHFQ scores between
groups observed after 12 weeks (7- and 3-point improve-
ment in the m-Ullevaal and MICT groups) also suggests the
importance of exercise in these group of patients. In the
present study, both CR groups showed a clinical improve-
ment because it’s already proven that a 5-point change in
total MLHFQ score is considered clinically important. 11
6MWT results had significantly improved more in the m-
Ullevaal than in the MICT group. This finding suggests the
superiority of the above-mentioned training program in
these patients. However, the sample size in our study was
small, and this finding needs further investigation in large
trials. According to the guidelines issued from the American
Thoracic Society (ATS),12 the minimal clinical significant
difference, reported through the 6MWT in patients with
CHF, is 43 m, and both groups reached this value in the
present study.
4. Conclusion
Our analysis verifies previous findings, which suggest that
CR models can improve both QoL and functional capacity of
patients with CHF. However, the improvement was greater
in the m-Ullevaal group; a finding that indicates a superi-
ority of this CR model in the Bulgarian population. Despite
the fact that the overall benefits of the HIAIT group exceed
those of the MICT group in terms of patients’ functional
capacity and QoL, further research and evidence are
needed for its solid clinical application. The aforemen-
tioned imply that our findings are consistent with the
existing literature, which indicates that CR programs are
beneficial in terms of QoL and functional capacity
improvement.
Appendix A. Supplementary data
Supplementary data related to this article can be found at
http://dx.doi.org/10.1016/j.hjc.2017.04.003.
Please cite this article in press as: Papathanasiou J, et al., The effect of group-based cardiac rehabilitation models on the quality of life
and exercise capacity of patients with chronic heart failure, Hellenic Society of Cardiology (2017), http://dx.doi.org/10.1016/
j.hjc.2017.04.003
3
MICT
P Baseline (T1) Follow up (T2) Difference P
T2-T1 (%)
35.81
8.56 - 6.42
3.06 <0.001
<0.001 436.5
41.9 480.2
43.9 10
2.6 <0.001
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Jannis Papathanasiou, MD, PhD *
Department of Kinesitherapy, Faculty of Public Health,
Medical University of Sofia, Bulgaria
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4 Letter to the Editor

Department of Medical Imaging, Allergology & Dorothea Tsekoura

Physiotherapy, Medical University of Plovdiv, Bulgaria Aretaieio Hospital, Athens Medical School, Athens, Greece

Nikolay Boyadjiev Yannis Dionyssiotis

Department of Medical Physiology and Sport Medicine, Physical Medicine & Rehabilitation Department, European
Medical University of Plovdiv, Bulgaria Interbalkan Medical Center, Thessaloniki, Greece

Donka Dimitrova Stefano Masiero

Department of Health Management and Health Economics, Department of Neuroscience, Section of Rehabilitation,
Medical University of Plovdiv, Bulgaria University of Padova, Padova, Italy

Petya Kasnakova
Department of Rehabilitation, Medical College, Medical
University of Plovdiv, Bulgaria
Zaharias Tsakris
Department of Kinesitherapy, Faculty of Public Health,
Medical University of Sofia, Bulgaria
Department of Medical Imaging, Allergology &
Physiotherapy, Mediccal University of Plovdiv, Bulgaria
*Corresponding author. Jannis Papathanasiou, MD, PhD,
Department of Kinesitherapy, Faculty of Public Health,
Medical University of Sofia, Bulgaria, Department of Medi-
cal Imaging, Allergology & Physiotherapy, Medical Univer-
sity of Plovdiv, Bulgaria
Tel.: þ359889101178; fax: þ35932940606.
E-mail address: giannipap@yahoo.co.uk (J. Papathanasiou)
2 February 2017
Available online XXX

Please cite this article in press as: Papathanasiou J, et al., The effect of group-based cardiac rehabilitation models on the quality of life
and exercise capacity of patients with chronic heart failure, Hellenic Society of Cardiology (2017), http://dx.doi.org/10.1016/
j.hjc.2017.04.003