Wednesday, February 05, 2020 PTJ: New CPG Supported by APTA Provides Guidance on PT Treatment of Individuals With Heart Failure In this review: Physical Therapist Clinical Practice Guideline for the Management of Individuals With Heart Failure (PTJ, January 23, 2020) The Message A new clinical practice guideline supported by APTA and developed by the Cardiovascular and Pulmonary Section of APTA includes nine evidence-based action statements for the evaluation and management of patients diagnosed with heart failure and two clinical algorithms to support clinical decision making. Physical therapy interventions can improve activity level, participation, and quality of life, as well as reduce hospital readmissions for individuals with heart failure, authors write, and PTs should "work collaboratively with other members of the health care team" to achieve these goals. The Study Authors developed the algorithms and action statements based on 127 systematic reviews, meta-analyses, and previously published CPGs that tested interventions used by physical therapists, reviewed randomized controlled trials, tested outcomes relevant for physical therapist practice, and included only patients who acquired heart failure as adults. A team of Cardiovascular and Pulmonary Section members representing both educators and clinicians appraised the quality of CPGs using the Appraisal of Guidelines, Research and Evaluation (AGREE II) tool, systematic reviews using the Assessment of Multiple Systematic Review (AMSTAR) tool, and RCTs using the University of Oxford Centre for Evidence-Based Medicine critical appraisal tool. Members of the CPG’s Guideline Development Group formulated and graded nine key action statements, which were then reviewed by internal and external stakeholders for comment. Development of the CPG was supported through an APTA-sponsored program that assists APTA sections — in the case, the Cardiovascular and Pulmonary Section — with funding and tools for CPG activities related to drafting, appraisal, planning, and external review (for more detail on the program, visit APTA's CPG Development webpage). Findings Nine broad action statements were recommended by the authors based on evidence strength identified as "strong" or "moderate." Each statement includes specific details on benefits, risks, benefit-harm assessment, role of patient preferences, and a summary of the supporting evidence. The recommendations for physical therapy prescriptions include specific parameters, which are detailed in the CPG. For all patients with heart failure: PTs should advocate for a "culture of physical activity as an essential component of care in patients with stable heart failure." (Strong recommendation) "Make appropriate nutrition referrals, perform medication reconciliation, and provide appropriate education on preventive self-care behaviors to reduce the risk of hospital readmissions." (Strong recommendation) For patients with stable, Class II to III heart failure as defined by the New York Heart Association: PTs should prescribe aerobic exercise training. (Strong recommendation) For patients with stable, NYHA Class II to III heart failure with reduced ejection fraction, also known as HFrEF, PTs should prescribe: Resistance training for the upper and lower body. (Strong recommendation) Neuromuscular electrical stimulation. (Strong recommendation) Inspiratory muscle training with a threshold (or similar) device (Strong recommendation) High-intensity, interval-based exercise — HIIT — for patients without contraindications. (Moderate recommendation) For patients with stable, NYHA Class II to III HFrEF, PTs may prescribe: Combined aerobic and resistance training. (Moderate recommendation) Combined inspiratory muscle training and aerobic exercise training. (Moderate recommendation) Authors developed two separate algorithms for patients with heart failure: the first to help PTs determine whether a patient is stable enough to proceed with an intervention and recognize when a person's signs and symptoms may require emergency medical treatment, and the second to assist in identifying which of the CPG's action statements are "most appropriate for a particular patient based on participation, activity, endurance, and signs of exercise intolerance." Why it Matters Noting the increasing readmissions rate and rising health care costs associated with heart failure, authors hope the CPG will "provide physical therapists with evidence-based recommendations that assist in improving functional capacity and [health-related quality of life] and reducing hospital readmissions for individuals with HF." As "integral members of the interprofessional team assisting with early detection of HF exacerbation and directing medical follow-up," PTs are urged by the authors to "work within their health care systems to determine how these or similar algorithms for identification of HF exacerbation can be utilized within their specific contexts and patient care environments." More From the Study In addition to their recommendations, authors described a number of areas needing further research, including but not limited to associations for variations in outcomes; effectiveness of specific exercise options; and appropriate exercise, dosing, and parameters for patients in different care settings. Small sample sizes, strict patient selection criteria, lack of functional outcome measures, study in limited settings, and other factors in existing research limited findings and recommendations in some areas. Keep in Mind … As with most CPGs, authors caution therapists that the recommendations are directed at a patient population but can't "address each unique situation of an individual patient." Authors also point out that the second algorithm, developed to help determine which recommendations are most appropriate for a particular patient, is based on expert opinion. The Guideline Development Group notes that the available research "did not address specific examination-based criteria for when any of the interventions reviewed herein are appropriate." Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.