Heart failure is not a single disease, but rather a clinical condition with a variety of aetiologies and pathophysiologies (Bozkurt et al, 2021). It is a complex clinical syndrome that results from any structural or functional impairment of ventricular filling or ejection of blood. The cardinal manifestations of heart failure are dyspnoea and fatigue that may limit exercise tolerance, fluid retention that can cause pulmonary congestion, and/or peripheral oedema (McDonagh et al, 2021; National Institute for Health and Care Excellence (NICE), 2018).
In the UK, close to 1 million people are living with heart failure (NICE, 2018; Bellanca et al, 2023; British Heart Foundation, 2024), with 3.6 million people affected in Northwest Europe, and projections indicate a rise to 5 million by 2025 (Savarese et al, 2023). The figures indicate that, in the UK, every year 200 000 people are diagnosed with heart failure, with the NHS spending 2% of its budget on managing the condition (Lawson et al, 2019; McDonagh et al, 2021). In western nations, prevalence is predicted to increase further to affect 3% of the population by 2025 (Barrett et al, 2019).
The reasons put forward for the continuing rise in the overall number of individuals with heart failure include a growing and ageing population, as well as an increase in the incidence of comorbidities, including diabetes, hypertension and obesity, which add to the pathophysiology of heart failure (Campbell et al, 2024).
In Western nations, the prevalence of heart failure has been estimated as doubling with each decade of life, increasing to more than 10% for those aged over 75 years (Ziaeian and Fonarow, 2016). It is the primary cause of hospitalisation for patients aged 65 years or older, with significant negative societal impact and economic consequences (Amin et al, 2021). The American Heart Association (Benjamin et al, 2017) predicts that the USA will see a 46% rise in the prevalence of heart failure between 2012 and 2030, meaning that 8 million or more Americans aged 18 years or older will be affected.
A systematic review by Lesyuk et al (2018) found that expenditure on the management of heart failure varies across the world, with costs averaging around £10 000 per patient a year. They estimated a lifetime cost of more than £100 000, with the highest expenditure going on hospital admissions. In the present health environment, these unaffordable expenses make necessary a paradigm change in order to reduce hospital admissions and enhance community care. It will thus require immediate steps to implement creative ways of controlling this projected demand for services into place.
Despite continuous advancements in chronic heart failure survival, the mortality rate is still high. A recent systematic review and meta-analysis by Jones et al (2019) found that, across healthcare settings, 5-year survival is close to 50%. Significant improvements in prognosis might result from a greater use of evidence-based therapy. This article seeks to support recommendations made by Jones et al (2019) for future analysis on the barriers and facilitators of treatment. A decade ago, best practice guidance on improving cardiovascular disease outcomes published by the Department of Health (DH) noted that around 4% of people with heart failure participate in cardiac rehabilitation and that increasing the proportion of those who do contribute to reducing mortality and hospitalisation (DH, 2013; NICE, 2018).
Cardiac rehabilitation
Heart failure guidelines (NICE, 2018; Tsutsui et al, 2021; Heidenreich et al, 2022) support cardiac rehabilitation as an intervention to reduce cardiovascular events, increase exercise tolerance, and enhance patients' quality of life (QoL). Updated European Society of Cardiology guidelines (McDonagh et al, 2021) recommend home-based and/or centre-based programmes as a 1A classification in reducing hospital admissions and mortality (Table 1). Class I covers conditions for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful and effective.
Table 1. Multidisciplinary interventions recommended for the management of chronic heart failure
| Recommendations | Class | Level of evidence | |
|---|---|---|---|
| It is recommended that heart failure (HF) patients are enrolled in a multidisciplinary HF management programme to reduce the risk of HF hospitalisation and mortality | I | A | |
| Self-management strategies are recommended to reduce the risk of HF hospitalisation and mortality | I | A | |
| Either home-based and/or clinic-based programmes improve outcomes and are recommended to reduce the risk of HF hospitalisation and mortality | I | A | |
| Influenza and pneumococcal vaccinations should be considered in order to prevent HF hospitalisations | IIa | B | |
| I | Evidence and/or general agreement that a given treatment or procedure is beneficial, useful and effective | A | Data derived from multiple randomised clinical trials or meta-analyses |
| IIa | Weight of evidence and/or divergence of opinion about the usefulness/efficacy of the given treatment or procedure | B | Data derived from a single randomised clinical trial or large non-randomised studies |
Adapted from: McDonagh et al, 2021: 35
Cardiovascular rehabilitation programmes aim to counteract the physiological and psychological effects of cardiovascular disease (CVD) and achieve clinical stabilisation (Scherrenberg et al, 2021). Cardiac rehabilitation is a multidisciplinary intervention the fundamental elements of which are widely acknowledged (NICE, 2018; Tsutsui, 2021; McDonagh et al, 2021; Heidenreich et al, 2022). These elements include physical activity counselling, diet counselling, psychosocial management, patient assessment, medication management, including optimising guideline-directed medical therapy and reduction of cardiovascular risk factors, and vocational support (Ambrosetti et al, 2021). It is anticipated that rehabilitation programmes would minimise hospital stays and cardiovascular events, and reduce early mortality; they would also maximise cardiovascular risk management and improve the psychosocial and occupational standing of participating patients (Scherrenberg et al, 2021). In the UK, 27% of all deaths are attributable to heart and circulatory diseases, which is more than 170 000 deaths a year, (British Heart Foundation, 2024). The British Society for Heart Failure has set a target for healthcare organisations to reduce deaths due to heart failure by 25% over the next 25 years through early detection and prompt treatment (https://www.bsh.org.uk/25in25).
Ruano-Ravina et al's (2016) systematic review identified a substantially lower participation in and adherence to cardiac rehabilitation among certain demographic groups: these included older adults, women, patients with comorbidities, single and unemployed individuals, those on lower incomes and those with lower educational levels. The findings suggested that qualitative studies could provide specific input as to patients' attitudes towards cardiac rehabilitation programmes. Promoting the benefits of cardiac rehabilitation with heart failure patients and gaining a better understanding of the patient's experience may facilitate uptake in cardiac rehabilitation and potentially improve cardiovascular outcomes.
Telerehabilitation
Telerehabilitation offers a solution to the low uptake of cardiac rehabilitation, as demonstrated by the EUROASPIRE surveys (Kotseva et al, 2019), which is due to difficulties with transport to appointments, frailty, competing schedules and low health literacy. Telerehabilitation is a service provided at a distance through either audio and/or video digital technology (Russell, 2007; Dinesen et al, 2019), which aims to address patients' needs through diagnostic, therapeutic, preventative, counselling, rehabilitating and consultative services (Shem et al, 2022). A wide range of communication tools, eg telephones, video consultations, the internet, smartphone apps, text messaging, email and social media, may be employed to deliver complete telerehabilitation treatments (Scherrenberg et al, 2021). All these options provide opportunities for reciprocal communication between patients and healthcare providers.
The term ‘telerehabilitation’ refers to these specific methods used in the field of rehabilitation. It is a subspecialty of telemedicine that includes holistic remote control of rehabilitation, such as medication titration, clinical observation readings, symptom assessment, exercise, and nutrition monitoring and guidance (Peretti et al, 2017). Although the field of rehabilitation in health care dates back several decades (Peretti et al, 2017), new telecommunication-based practices have emerged globally more recently (López et al, 2020; Tsutsui et al, 2021; Valverde-Martinez et al, 2023). The earliest scientific publication on the topic, according to Peretti et al (2017), was published in 1998 – and there are reports of its earlier use (Oncall Health Qualifacts (2021) – telerehabilitation has gained increasing popularity in every field of medicine over the past 25 or so years (Cottrell et al, 2017; Cristo et al, 2018; Appleby et al, 2019; López et al, 2020; Grundstein et al, 2021; Tsutsui et al, 2021; Isernia et al, 2022).
Research supports the advantages of telerehabilitation for other medical conditions such as osteoarthritis (Xie et al, 2021), stroke (Tchero et al, 2018) and palliative care (Vincent et al, 2022). Its growth in popularity has been fuelled by changing health needs and demographics, with people living longer with more comorbidities and chronic illness, as well as due to the development of cutting-edge computer and communications technology (López et al, 2020; Valverde-Martinez et al, 2023).
Cleland et al's (2005) research, which was among the earliest studies to investigate home telemonitoring for heart failure patients, emphasised the need to develop new approaches, for example using digital tools, to manage patients with heart failure at home. More recent research identifies telerehabilitation as an effective component of heart failure management, which can help overcome perceived barriers to cardiac rehabilitation, such as travel to appointments, long waiting times and accessibility (Cavalheiro et al, 2021; Skov Schacksen et al, 2021). It is a strategy that enables patients to have interventions at home without the need for healthcare staff to be present on-site (Piotrowicz et al, 2016; Thomas et al, 2018). Telerehabilitation therefore offers an innovative, practical approach to improving access to cardiac rehabilitation in both urban and rural regions (Thomas et al, 2018; Nagatomi et al, 2022) and engaging diverse patient groups (Ruano-Ravina et al, 2016).
Conrad et al's (2018) population-based study in the UK showed that, over a 12-year period, an average of 79% of heart failure patients had three or more comorbidities such as diabetes, chronic kidney disease or chronic obstructive pulmonary disease, which adds to the challenges in management. Telerehabilitation affords patients timely consultations and monitoring, particularly as the interplay between other illnesses may impact on their ability to travel to clinic-based appointments (Skov Schacksen et al, 2021). A randomised controlled trial by Nelson et al (2021) assessed the cost-effectiveness of telerehabilitation compared with traditional face-to-face care, demonstrating that the expenses and outcomes of telerehabilitation were comparable with those of conventional in-person therapy. The research also showed that telerehabilitation greatly decreased the time commitment required of patients and carers.
Furthermore, telerehabilitation can contribute to the reduction of the NHS carbon footprint: the Health and Care Act 2022 sets out plans to deliver a net-zero NHS, with the aim of achieving an 80% reduction by 2028 (NHS England, 2022). Purohit et al's (2021) systematic review presents the argument for telemedicine's possible role in the transition to a healthcare system with net-zero carbon emissions. Their research found a significant association between the average trip distance saved and the reduction in carbon footprint, indicating that most environmental benefits are the consequence of reduced travel to appointments (Purohit et al, 2021).
The World Health Organization (WHO) (2018) developed a framework that categorises digital health treatments into 28 groups, facilitating more open comparisons of technology designed to address related healthcare issues. Telehealth has been employed in health care for a considerable time. Eddison et al (2023) obtained information on telemedicine delivered by allied health professionals across a number of NHS organisations, leading the researchers to conclude that the use of telemedicine in the NHS can offer patients a more person-centred pathway. A policy paper from the Department of Health and Social Care (DHSC) (2022) recognised the potential value of telehealth, stating that digital technology will be essential to patient care in the future. The DHSC paper makes a commitment to scaling up digital self-help, diagnostics and therapies.
Remote patient-clinician consultations, case management, remote health data monitoring, and data transfer to healthcare providers are all made possible by digital technologies (WHO, 2018). There has been an acceleration in the use of telemedicine following the COVID-19 pandemic, although as already mentioned, there have been references to telemedicine as far back as the 1940s (Oncall Health Qualifacts, 2021). A review by Jaswal et al (2023) analysed the rapid implementation of telehealth and telerehabilitation after the onset of the pandemic, concluding that, although there has been a burgeoning in these approaches, more research is needed to evaluate their effectiveness. In a review of studies that investigated the effectiveness of telerehabilitation with regard to post-COVID symptoms, Valverde-Martinez et al (2023) came to the same conclusions: they concur that more research is necessary to assess the effectiveness of this approach.
Zhu et al (2020), who carried out a meta-analysis of research on telemedicine approaches for patients with heart failure, reported that it appears to be advantageous compared with traditional health care. Such interventions were especially beneficial in terms of lowering all-cause hospitalisation, cardiac hospitalisation, all-cause mortality, cardiac mortality, and duration of stay for heart failure patients. The meta-analysis by Zhu et al (2020) found few studies examining patients' experiences and the relationship between patients' education and their adherence to, and adoption of, telemonitoring.
One study, by Testa et al (2020), however, investigated these links. They adopted a narrative approach to gather the stories and perspectives of patients, their carers and heart failure specialists about living with heart failure. The impact described in the narratives focused mostly on the emotional and social limitations that patients and carers experienced daily, which hampered their ability to do their jobs and affected their social lives and the hobbies they could do. Testa et al (2020) suggested that the stories of great distress and suffering shared by patients and carers may have been prompted by the general lack of knowledge about heart failure. The narratives revealed varying degrees of awareness about the condition. Possible causes of this literacy deficit could be limited communication, failure to interpret the meaning of the illness experience, and failure to recognise carers as essential components of the care pathway who can help raise awareness of the illness and coping mechanisms (Testa et al, 2020). More research may help to inform the development of heart failure pathways, with telerehabilitation serving as a vital link for regular communication and illness tracking to promote adaptability and timely therapy integration.
Qualitative studies on patient perspectives and experiences of telerehabilitation have reported concerns about the lack of human interaction and face-to-face contact (Lefler et al, 2018; Son et al, 2020; Woo and Dowding, 2020). These concerns were compounded by fear about the reliability of the technology, the notion that face-to-face contact was more reliable for readings, and hesitancy to use new technology. In Woo and Dowding's (2020) work patients reported that they felt reassured by human interaction, which could also help alleviate feelings of isolation and loneliness, giving a sense of purpose and structure to their day. For example:
‘I enjoy [the] visiting nurse coming … if there is something going wrong with me, I would rather get in touch with the nurse service and have a human being come, rather than depend on a machine.’
Healthcare services should consider dedicating resources for the adoption of telerehabilitation in order to ensure that all eligible patients can be offered the option of telerehabilitation and to provide funding for both patient and staff training, to help to overcome technological challenges. To maximise the effectiveness of telerehabilitation programmes it is vital to consider the implementation of strategies such as consistent clinician support, combined with a hybrid model that combines face-to-face interactions with telerehabilitation. A more thorough integration of technology to deliver hybrid care, and to establish treatment guidelines that lead to effective and efficient care for patients with heart failure, is required within care-delivery business models.
Thinking ahead
As numbers of heart failure patients in our ageing populations rise, so too will the demand for services and treatment. It is therefore imperative to put in place legislative measures, rationalise patient treatment pathways, and improve healthcare delivery to meet the requirements of individuals with heart failure. Moreover, the anticipated shortage of staff by 2030 (WHO, 2016) makes all the more pressing the need for modernisation and innovative changes to provide person-centred delivery of health services.
A systematic review and meta-analysis of telerehabilitation approaches to patients with chronic heart failure revealed low adverse effects and improved functional capacity (Isernia et al, 2022). However, there was wide disparity across studies in Isernia et al's (2022) review in terms of both type and duration of treatments offered.
Conclusion
The development and implementation of telerehabilitation routes for heart failure patients are still in the early stages. From the studies reviewed in this article, it is clear that increased user engagement is necessary to maximise the advantages of this relatively new type of cardiac rehabilitation. Future research is required to address the key issue of integrating an engagement component into the telerehabilitation paradigm for heart failure.
KEY POINTS
- Heart failure is increasing in tandem with ageing demographics and growing numbers of patients with co-morbidities. The British Society for Heart Failure is spearheading an initiative to reduce deaths by 25% over the next 25 years
- Telerehabilitation has the potential to bring real benefits in terms of risk reduction, and improving access and uptake of cardiac rehabilitation
- Further research would help inform the standardisation of treatment pathways, including the integration of telerehabilitation, and the development of new approaches to offer the option of telerehabilitation to a population of heart failure patients to improve their quality of life, reduce symptom burden and reduce hospital admissions
CPD reflective questions
- Consider the gaps in care for heart failure patients in your clinical area. What could you do in your clinical setting to enhance the care of heart failure patients by, for example, promoting cardiac rehabilitation/telerehabilitation?
- Considering the findings described in this article: what forward planning could be done with your team to prepare for managing the growing prevalence of heart failure in the future?