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Hellenic Society of Cardiology (2017) xx, 1e4

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

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/
2 Letter to the Editor

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

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
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/
Letter to the Editor 3

Table 1 MLHFQ and Functional Capacity (6MWT) in both CR groups before and after CR interventions (mean SD).
Training Groups HIAIT (m-Ullevaal) MICT
Variable Baseline (T1) Follow up (T2) Difference P Baseline (T1) Follow up (T2) Difference P
T2-T1 (%) T2-T1 (%)
MLHFQ 37.376.66 30.926.54 - 17.263.78 <0.001 38.278.44 35.818.56 - 6.423.06 <0.001
6MWT (m) 443.242.9 506.339.3 14.54,7 <0.001 436.541.9 480.243.9 102.6 <0.001

patients with CHF can be associated, on the one hand, with References
their poor socioeconomic statusdmost of them are retired
with low pensions and low living standard. This situation is 1. Bowling CB, Fonarow GC, Patel K, Zhang Y, Feller MA, Sui X,
also worsened by a deepening economic crisis. On the other et al. Impairment of activities of daily living and incident heart
hand, they can also be interpreted in relation to the failure in community-dwelling older adults. Eur J Heart Fail.
problems of the healthcare system and its ongoing reforms. 2012;14:581e587.
Indicatively, difficulties of organizational and legal level, 2. Malik FA, Gysels M, Higginson IJ. Living with breathlessness: a
health insurance, and others (e.g., high rise in costs of survey of caregivers of breathless patients with lung cancer or
medication, restricted access to medical specialists, and heart failure. Palliat Med. 2013;27:647e656.
lack of national CR programs) are some of the aspects that 3. Wilhelmsen L, Rosengren A, Eriksson H, Lappas G. Heart failure
deteriorate the dynamics of the Bulgarian healthcare in the general population of menemorbidity, risk factors and
prognosis. J Intern Med. 2001;249:253e261.
4. Haykowsky MJ, Liang Y, Pechter D, Jones LW, McAlister FA,
The 10 -point difference in MLHFQ scores between Clark AM. A meta-analysis of the effect of exercise training on
groups observed after 12 weeks (7- and 3-point improve- left ventricular remodeling in heart failure patients: the
ment in the m-Ullevaal and MICT groups) also suggests the benefit depends on the type of training performed. J Am Coll
importance of exercise in these group of patients. In the Cardiol. 2007;19(49):2329e2336.
present study, both CR groups showed a clinical improve- 5. Takousi MG, Schmeer S, Manaras I, Olympios CD, Makos G,
ment because it’s already proven that a 5-point change in Troop NA. Health-Related Quality of Life after Coronary
total MLHFQ score is considered clinically important. 11 Revascularization: A systematic review with meta-analysis.
6MWT results had significantly improved more in the m- Hellenic J Cardiol. 2016 Aug 23. http://dx.doi.org/10.1016/j.
Ullevaal than in the MICT group. This finding suggests the hjc.2016.05.003.
6. Nilsson BB, Westheim A, Risberg MA. Effects of group-based
superiority of the above-mentioned training program in
high-intensity aerobic interval training in patients with
these patients. However, the sample size in our study was chronic heart failure. Am J Cardiol. 2008 Nov 15;102(10):
small, and this finding needs further investigation in large 1361e1365. http://dx.doi.org/10.1016/j.amjcard.2008.07.016.
trials. According to the guidelines issued from the American 7. MI Secondary Prevention: Secondary Prevention in Primary and
Thoracic Society (ATS),12 the minimal clinical significant Secondary Care for Patients Following a Myocardial Infarction:
difference, reported through the 6MWT in patients with Partial Update of NICE CG48 [Internet]. National Clinical
CHF, is 43 m, and both groups reached this value in the Guideline Centre (UK). London: Royal College of Physicians
present study. (UK); 2013 Nov. National Institute for Health and Clinical
Excellence: Guidance.
8. Papathanasiou J, Troev T, Ferreira AS, et al. Advanced Role and
4. Conclusion Field of Competence of the Physical and Rehabilitation Medi-
cine Specialist in Contemporary Cardiac Rehabilitation. Hel-
Our analysis verifies previous findings, which suggest that lenic J Cardiol. 2016;57:16e22.
CR models can improve both QoL and functional capacity of 9. Kendrick KR, Baxi SC, Smith RM. Usefulness of the modified 0-
10 Borg scale in assessing the degree of dyspnea in patients
patients with CHF. However, the improvement was greater
with COPD and asthma. J Emerg Nurs. 2000;26:216e222.
in the m-Ullevaal group; a finding that indicates a superi-
10. Bellet RN, Adams L, Morris NR. The 6-minute walk test in
ority of this CR model in the Bulgarian population. Despite outpatient cardiac rehabilitation: validity, reliability and
the fact that the overall benefits of the HIAIT group exceed responsivenessea systematic review. Physiotherapy. 2012;98:
those of the MICT group in terms of patients’ functional 277e286.
capacity and QoL, further research and evidence are 11. Rector TS, Tschumperlin LK, Kubo SH, et al. Use of the Living
needed for its solid clinical application. The aforemen- with Heart Failure Questionnaire to ascertain patients’ per-
tioned imply that our findings are consistent with the spectives on improvement in quality of life versus risk of drug-
existing literature, which indicates that CR programs are induced death. J Card Fail. 1995;1:201e206.
beneficial in terms of QoL and functional capacity 12. American Thoracic Society. ATS Statement: Guidelines for the
Six-Minute Walk Test. Am J Resp Crit Care Med. 2002;166:

Appendix A. Supplementary data Jannis Papathanasiou, MD, PhD *

Department of Kinesitherapy, Faculty of Public Health,
Supplementary data related to this article can be found at Medical University of Sofia, Bulgaria

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