Acute decompensated heart failure (ADHF) is the leading cause of hospitalizations in older persons, which markedly worsen quality-of-life, increase mortality and health care costs, and have been declared a national priority by CMS. However, current management strategies have had only modest impact on rehospitalizations for ADHF, and recent trials have been negative, suggesting a need for a new approach. Multiple lines of evidence suggest that severe impairments in physical function strongly contribute to adverse outcomes in older ADHF patients. Even when stable and well-compensated, older patients with chronic HF have severe impairments in physical function, which markedly worsen as they transition to ADHF. These are further exacerbated by hospital-related factors, including forced bed rest. After discharge, patients continue to have marked impairments in strength, balance, mobility, and endurance. Most patients meet formal definitions of frailty, and some never recover baseline function. This occurs during the highest risk period for early rehospitalization and adverse outcomes. We hypothesize that this cascade of events resulting in persistent, severe physical dysfunction contributes to the high rates of rehospitalization in older HF patients. However, current HF management paradigms do not address the marked impairments in physical function, and neither chronic nor acute HF are approved indications for cardiac rehabilitation. Furthermore, exercise training trials have excluded ADHF, and have also not included the domains of balance, strength and mobility which are important for preventing injuries in frail, older patients. To address this critical evidence gap, we developed a novel, tailored, progressive, multidisciplinary 12-week rehabilitation intervention beginning during hospitalization and designed to address the specific deficits in physical function of older ADHF patients. In our pilot study, this intervention was safe and produced a 17.9% improvement in the Short Physical Performance Battery (SPPB) score and a 29.3% reduction in all-cause rehospitalizations. The change in the SPPB score explained 90% of the reduction in all-cause rehospitalizations. The primary aim of the proposed study (REHAB-HF) is to conduct a multi-center, randomized, controlled, single-blind trial in 360 older patients with ADHF to test the primary specific hypothesis that the REHAB-HF intervention will improve physical function, as measured by the SPPB. The secondary aim is to collect clinical outcomes data during 6-month follow-up to test the hypothesis that the REHAB-HF intervention group will have a reduced 6-month all-cause rehospitalization rate. The investigators are a cohesive, highly experienced multidisciplinary team from three well-established sites. By testing a novel intervention supported by multiple levels of evidence, the REHAB-HF trial will address a critical evidence gap in the care of older patients with ADHF, the most common Medicare discharge diagnosis. The REHAB-HF results could shift clinical management paradigms, improve function, reduce costs, and change health care policy for the 1 million older patients per year with hospitalized ADHF.

Public Health Relevance

Acute heart failure, a disorder in which patients have severe shortness of breath and exertional fatigue, is the leading cause of hospitalization in older persons, and is associated with subsequent adverse events, particularly rehospitalizations. These patients have severely impaired physical function and this contributes to their adverse outcomes. The proposed study will test whether a specialized program of exercises designed to improve strength, balance, mobility, and endurance will improve overall physical function and reduce rehospitalizations. If so, this could have major impact on the 1 million persons per year with this disorder.

National Institute of Health (NIH)
National Institute on Aging (NIA)
Research Project (R01)
Project #
Application #
Study Section
Special Emphasis Panel (ZAG1-ZIJ-8 (J4))
Program Officer
Romashkan, Sergei
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
Wake Forest University Health Sciences
Internal Medicine/Medicine
Schools of Medicine
United States
Zip Code
Reeves, Gordon R; Whellan, David J; Duncan, Pamela et al. (2017) Rehabilitation Therapy in Older Acute Heart Failure Patients (REHAB-HF) trial: Design and rationale. Am Heart J 185:130-139
Upadhya, Bharathi; Kitzman, Dalane W (2017) Heart Failure with Preserved Ejection Fraction in Older Adults. Heart Fail Clin 13:485-502
Rogers, Joseph G; Patel, Chetan B; Mentz, Robert J et al. (2017) Palliative Care in Heart Failure: The PAL-HF Randomized, Controlled Clinical Trial. J Am Coll Cardiol 70:331-341
Kitzman, Dalane W; Haykowsky, Mark J; Tomczak, Corey R (2017) Making the Case for Skeletal Muscle Myopathy and Its Contribution to Exercise Intolerance in Heart Failure With Preserved Ejection Fraction. Circ Heart Fail 10:
Shaltout, Hossam A; Eggebeen, Joel; Marsh, Anthony P et al. (2017) Effects of supervised exercise and dietary nitrate in older adults with controlled hypertension and/or heart failure with preserved ejection fraction. Nitric Oxide 69:78-90
Luo, Nancy; Merrill, Peter; Parikh, Kishan S et al. (2017) Exercise Training in Patients With Chronic Heart Failure and Atrial Fibrillation. J Am Coll Cardiol 69:1683-1691
Bhatt, Ankeet S; DeVore, Adam D; Hernandez, Adrian F et al. (2017) Can Vaccinations Improve Heart Failure Outcomes?: Contemporary Data and Future Directions. JACC Heart Fail 5:194-203
Pandey, Ambarish; Kitzman, Dalane W; Brubaker, Peter et al. (2017) Response to Endurance Exercise Training in Older Adults with Heart Failure with Preserved or Reduced Ejection Fraction. J Am Geriatr Soc 65:1698-1704
Luo, Nancy; Teng, Tiew-Hwa Katherine; Tay, Wan Ting et al. (2017) Multinational and multiethnic variations in health-related quality of life in patients with chronic heart failure. Am Heart J 191:75-81
Mentz, Robert J; Peterson, Eric D (2017) Site Principal Investigators in Multicenter Clinical Trials: Appropriately Recognizing Key Contributors. Circulation 135:1185-1187

Showing the most recent 10 out of 31 publications