1. Yamazaki, Yota RPT, MS
  2. Ikeda, Yuki MD, PhD
  3. Shima, Hikaru RPT
  4. Mochizuki, Takehide RPT
  5. Sakamoto, Ryuichi MD, PhD
  6. Sawano, Koichi RPT

Article Content

The desirable outcome of treatment for elderly patients with heart failure (HF) is not necessarily a reduction in mortality, but rather an improvement in quality of life.1 For very elderly patients who have been living at home, unexpectedly not being able to return home due to an inpatient event resulting from HF can be a major factor in lowering quality of life.


Comprehensive cardiac rehabilitation (CCR) is a multidisciplinary and comprehensive process.2 We speculated CCR would contribute to elderly patients with HF having improved frequency of home discharge. The purpose of the present study was to determine the effect of CCR on home discharge for elderly patients hospitalized with HF.



This study was conducted as a single-center, retrospective cohort study. This study was conducted after receiving approval from the local institutional ethics committee at our institution. Inclusion criteria were patients aged >=80 yr who were hospitalized and medically treated for the diagnosis of acute decompensated HF at Shizuoka City Shimizu Hospital. Exclusion criteria were patients with missing values for echocardiography and blood sampling, with post-coronary artery bypass surgery, with acute myocarditis. The study period for patient enrollment was from April 1, 2014, to January 31, 2020.


Data for statistical analyses were collected from clinical records. The CCR included a system of ambulation including initiating exercise, in consultation with the attending physician, as the symptoms of HF and cardiovascular status improved. A multidisciplinary conference with physicians, nurses, pharmacists, medical social workers, dieticians, physiotherapists, and occupational therapists was held within 1 wk from admission. During the conference, problems during hospitalization and identified causative diseases of HF were shared, and then factors that may be barriers to home discharge and their countermeasures were discussed.


There was no involvement of a cardiologist from April 2014 to March 2017. Therefore, participants were divided into groups according to the presence or absence of a cardiologist (from April 2017) and the implementation of a multidisciplinary approach from the time of admission. In other words, CCR was the group with intervention by cardiologists and multidisciplinary approach from the time of admission to the hospital, while non-CCR was the group with intervention by general physicians and rehabilitation physiotherapy before discharge if necessary. All participants were hospitalized patients. For outcome evaluation, 6-mo mortality and home discharge were also observed. We further examined days from admission to ambulation, the improvement in Barthel index change during hospitalization, the continuous walk distance in 6-min walk test at discharge, body mass index at discharge, and days to medical social worker intervention.



Propensity score matching was used to adjust for the confounding of patient backgrounds between the groups. The explanatory variables were age, left ventricular ejection fraction, B-type natriuretic peptide, and estimated glomerular filtration rate. Unpaired t and [chi][superscript digit two] tests were performed to examine differences in patient demographics, 6-mo mortality, and home discharge rates between the groups with SPSS Statistics version 22 (IBM). All judgments of significance were made with a risk rate of 5%.



A total of 375 hospitalized patients with HF were included. Twenty patients with missing echocardiography, three after coronary artery bypass surgery, two with acute myocarditis, and three who were transferred to other hospitals were excluded. After exclusion, 347 patients (84.3 +/- 8.9 yr old; 42% female) were eligible for this study. Patients in the CCR group were older, showed higher left ventricular ejection fraction, higher B-type natriuretic peptide, and lower estimated glomerular filtration rate than those in the non-CCR group.


After propensity score matching, the number of patients in both the CCR group and the non-CCR group was 136. The mean age of the patient population was 83.5 +/- 10.6 vs 85.2 +/- 8.2 yr (CCR vs non-CCR), and 38 male (28%) vs 43 (32%). The average left ventricular ejection fraction was 47.6 +/- 13.9 vs 53.2 +/- 13.9%. The average B-type natriuretic peptide was 1049.2 +/- 1023.4 vs 1001.0 +/- 1083.4 pg/mL. The average estimated glomerular filtration rate was 47.6 +/- 13.9 vs 48.7 +/- 22.2 mL/min/1.73 m2. After propensity score matching, there was no significant difference in baseline characteristics between the groups.


The CCR group did not have a significantly lower 6-mo mortality rate but had a significantly higher home discharge rate than the non-CCR group both before and after propensity score matching (Figure). Comparison of clinical progress after propensity score matching showed that patients in the CCR group had higher increase in change in the Barthel index score during hospitalization (CCR vs non-CCR: +55.6 +/- 25.2 vs +35.1 +/- 24.8), shorter time from admission to discharge (3.1 +/- 2.2 vs 6.1 +/- 2.1 d), longer continuous 6-min walk distance at discharge (153 +/- 53 vs 74 +/- 55 m), and shorter time to medical social worker intervention (3.3 +/- 3.8 vs 13.1 +/- 8.7 d).

Figure. Comparison o... - Click to enlarge in new windowFigure. Comparison of (A) 6-mo mortality and (B) home discharge rate before propensity score matching; (C) 6-mo mortality and (D) home discharge rate after propensity score matching. Abbreviation: CCR, comprehensive cardiac rehabilitation.

We identified 66 deaths (24.2% of the total). Of these, 20 (7.4% of the total) were due to cardiovascular events resulting from heart disease, and 46 (16.9% of the total) deaths were due to noncardiovascular events.



The major finding of this study was that CCR was an important procedure in the clinical approach for home discharge. However, it was not associated with mortality for elderly patients hospitalized with HF.


Comprehensive cardiac rehabilitation for inpatients with HF has been shown to ameliorate activities of daily living at discharge.3,4 Lower activities of daily living score at discharge creates an increased burden of care for the family after discharge and makes home discharge difficult. Early hospital discharge support is another factor in home discharge.5 It has been suggested that considering the necessity of introducing long-term care insurance by nurses and medical social workers early after hospitalization will enable patients to continue medical care in the community.6 The major limitation of this study was the presence of selection bias by a single institution.


In conclusion, CCR for elderly patients hospitalized with acute decompensated HF had a limited impact on patient outcomes, but contributed to improved home discharge. Further investigations are necessary to evaluate the effects of rehabilitation focusing on improving patient quality of life.


Yota Yamazaki, RPT, MS


Shizuoka City Shimizu Hospital, Shizuoka, Shizuoka, Japan


Yuki Ikeda, MD, PhD


Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan


Hikaru Shima, RPT


Shizuoka City Shimizu Hospital, Shizuoka, Shizuoka, Japan


Takehide Mochizuki, RPT


Shizuoka City Shimizu Hospital, Shizuoka, Shizuoka, Japan


Ryuichi Sakamoto, MD, PhD


Shizuoka City Shimizu Hospital, Shizuoka, Shizuoka, Japan


Koichi Sawano, RPT


Shizuoka City Shimizu Hospital, Shizuoka, Shizuoka, Japan




1. Tsutsui H, Isobe M, Ito H, et al JCS 2017/JHFS 2017 Guideline on Diagnosis and Treatment of Acute and Chronic Heart Failure-Digest Version. Circ J. 2019;83(10):2084-2184. [Context Link]


2. La Rovere MT, Traversi E. Role and efficacy of cardiac rehabilitation in patients with heart failure. Monaldi Arch Chest Dis. 2019;89(1). doi:10.4081/monaldi.2019.1027. [Context Link]


3. Kakutani N, Fukushima A, Kinugawa S, et al Progressive mobilization program for patients with acute heart failure reduces hospital stay and improves clinical outcome. Circ Rep. 2019;1(3):123-130. [Context Link]


4. Long L, Mordi IR, Bridges C, et al Exercise-based cardiac rehabilitation for adults with heart failure. Cochrane Database Syst Rev. 2019;1(1):CD003331. [Context Link]


5. Gil M, Mikaitis DK, Shier G, Johnson TJ, Sims S. Impact of a combined pharmacist and social worker program to reduce hospital readmissions. J Manag Care Pharm. 2013;19(7):558-563. [Context Link]


6. Sverdrup K, Bergh S, Selbaek G, Roen I, Kirkevold O, Tangen GG. Mobility and cognition at admission to the nursing home-a cross-sectional study. BMC Geriatr. 2018;18(1):30. [Context Link]