Heart Failure Help: Preventing Hospital Readmissions

Q: What’s the biggest misconception about heart failure?

A: Many people believe that exercise will harm the heart. But studies show that exercise is safe and beneficial, even for a patient with an implantable cardioverter-defibrillator. In a large study of exercise in patients with heart failure, there were no abnormal firings with exercise. Efforts to improve the heart’s pumping ability typically begin with drugs—ACE inhibitors, bet

Heart failure—the weakening of the heart’s pumping ability—can result from heart-muscle damage caused by a heart attack. The right treatment can prevent further damage, improve the heart’s pumping power and possibly even restore heart health. But receiving optimal treatment can be a challenge. Of the approximately one million Americans hospitalized each year for heart failure, one in five returns to the hospital within a month.

Ileana L. Piña, M.D., M.P.H.Physician-scientist Dr. Ileana L. Piña, professor of medicine (cardiology) and of epidemiology & population health at Einstein, wants to succeed where the system so far has failed. “We’re trying to find the best way to bring these patients safely home, get them well medicated and keep them out of the hospital with a good quality of life,” said Dr. Piña, also associate chief in the division of cardiology at the Montefiore Einstein Center for Heart & Vascular Care.

The Exercise Effect

Dr. Piña’s research focuses on exercise training for treating heart failure. As an investigator for the HF-ACTION (Heart Failure–A Controlled Trial Investigating Outcomes of Exercise Training) study of the National Heart, Lung and Blood Institute, she and her colleagues found that heart-failure patients who completed a 12-week exercise program were 11 percent less likely to be rehospitalized, and their average medical costs were $5,320 lower than those treated with medi­cation alone.

Based on these find­ings, Medicare recently changed its reimbursement rules to cover cardiac rehabilitation programs for heart-failure patients. The new cov­erage will “encourage patients to join a formal program so they feel safe and secure, and then they can continue at home,” said Dr. Piña. “Fewer hospitalizations for patients will save money, and their quality of life will improve.”

Women are twice as likely as men to develop heart failure after a heart attack or bypass, yet they’re less likely to be referred to a cardiac rehabilitation program or to complete an exercise training program. Why?

This article originally appeared in the spring/summer 2015 issue of the Wilf Family Cardiovascular Research Center Newsletter.“There wasn’t as much evidence that exercise training benefited women with heart failure compared with men—mainly because of the small numbers of women in trials and the lack of baseline data,” says Dr. Piña. Women made up 28 percent of the 2,331 patients in HF-ACTION. After comparing women who underwent exercise training with women who didn’t, Dr. Piña and her colleagues found a significant 26 percent reduction in all-cause death or all-cause hospital stays in women who exercised; this was the first analysis to report such results. “Exercise training for women with heart failure appears to be a useful addition to medical therapy,” said Dr. Piña.

New Discharge Strategies

Tightening up overall management is also essential. Dr. Piña was a co-author of an Institute for Healthcare Improvement and American College of Cardiology study that identified hospital strategies in addition to ex­ercise that could help reduce 30-day readmission rates for heart-failure pa­tients. Among the most effective were avoiding medication errors, arranging follow-up appointments before dis­charge and making sure the patient’s primary physician received discharge notes or electronic summaries.

“Heart failure is a team-care syn­drome,” said Dr. Piña. At Montefiore, that team includes nurse practitioners and pharmacists who optimize drug dosages and make sure patients know how to take their medications; nutri­tionists who teach low-sodium cook­ing; physical therapists who encour­age patients to enroll in supervised rehabilitation programs; and behav­ioral modification experts who help patients stop smoking, lose weight and follow their doctors’ instructions.