Heart-failure patients can exercise

Contrary to popular belief, people with heart failure can work out at the gym, ride bikes and participate in other exercises that once were considered dangerously strenuous, a large international study led by Duke University researchers has found.

The findings free heart patients to be active, and are likely to fuel an effort to change public policy, study authors say. Currently, Medicare and many private insurers do not cover doctor-guided exercise programs for patients who have heart failure.

The disease, which afflicts 5 million Americans, is diagnosed when the heart loses pumping force because of blockages, a heart attack or other causes. Treatments costs Medicare more than $4.5 billion a year.

For many doctors, the lack of insurance coverage was stuck in old fears that exercise would create a strain that could kill heart failure patients. In more recent years, smaller studies have shown that exercise is helpful, but the findings weren't large enough to influence coverage decisions.

The Duke study was designed in size and scope to be definitive. It followed 2,331 patients at 82 health centers in the United States, Canada and France for more than two years. Half the patients got the normal care, including checkups and hypertension drugs. The other half got normal care, plus they were asked to start exercising on a treadmill or stationary bike for 30 minutes at least three times a week.

"We were very pleased, first and foremost, to see the safety," said Dr. Christopher O'Connor, a Duke cardiologist who presented the study's findings Tuesday during a meeting of the American Heart Association.

But there wasn't a blockbuster finding that exercise is hugely beneficial to heart failure patients. Physical activity appears to offer no extra protection from overall hospitalizations or death, although it does result in a 15 percent lower risk of major cardiac events.

O'Connor said exercise might actually be more helpful than the findings indicate, because the study skewed care. Participants in the non-exercise group got intensive time and attention from doctors as part of the research, and some may have worked out on their own -- factors that likely improved their health.

"In the real world, the lift [provided by exercise] will be higher," O'Connor said.

Drop-off in exercise

Perhaps the biggest impediment facing the researchers was the drop-off in compliance among the exercise group. By the end of the study, only about half of those assigned to exercise were working out the minimum three times a week -- a phenomenon among all heart patients that has long frustrated doctors.

"It's a matter of changing behavior," said Dr. Sidney Smith Jr., a cardiologist at UNC-Chapel Hill and past president of the American Heart Association. "People are quite willing to take a pill or have a procedure, but it's another thing to get them to diet, stop smoking and exercise."

Patients who adhered to the exercise program said they saw concrete results.

Kenny Jones, 51, said he never exercised before he suffered a massive heart attack in 2003. A golfer, Jones said that even riding a golf cart, he would get tired after playing nine holes. He started the Duke trial in 2006, and has worked up to one-hour sessions on the treadmill four days a week. Now, he said, he feels like he could walk 36 holes, carrying his bag.

"Oh wow, I have more stamina, more confidence, and I'm able to do more things," said Jones, of Durham. "There's really a lot of benefit in exercising."

Smith, who was not involved in the study but heard the presentation Tuesday, said he sees improvement in his heart failure patients who exercise, and he recommends it. He said the study reinforces the growing perception among cardiologists that exercise is an inexpensive and effective therapy for nearly all people with cardiovascular disease.

And, Smith said, patient compliance might actually improve if the findings could influence the availability of insurance coverage.

"It would remove a barrier" to care, he said.

Lack of proof cited

Cardiac rehabilitation costs about $30 a session and includes doctor-guided exercise regimens, plus drug compliance counseling and other interventions. It has long been standard therapy after heart attacks.

In 2006, the Centers for Medicare and Medicaid Services, which oversees the federal government's health insurance programs, expanded coverage to pay for cardiac rehab after heart valve repair, angioplasty and even heart-lung transplants. It explicitly ruled out coverage for heart failure, however, citing a lack of proof that it was necessary.

O'Connor said officials at CMS are aware of the heart failure trial, but no cost analysis of adding cardiac rehab coverage for heart failure has been conducted. A spokesman for CMS said Tuesday that current costs of cardiac rehab were not readily available, and the offices were closed for the Veterans Day holiday.

"Probably next spring we will set up a meeting and advocate for change," O'Connor said.