Congestive Heart Failure (CHF)
in a 79-Year Old Male
How does distance walked in 6 minutes
relate to re-hospitalization?
Clinical Problem Solving I
Kaylea Kirven
Purpose:
• To describe the physical therapy –
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Examination
Evaluation
Plan of care
Outcomes
• To examine research related to my prognostic
question –
▫ Is 6-minute walk test distance a prognostic
indicator for re-hospitalization in elderly male
patients with severe congestive heart failure?
“Mr. C”
• 79 year old male
• Admitted to hospital presenting with:
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Abdominal pain
Shortness of breath
Dizziness
Dysphagia
Weight gain of 23 lbs
• Past Surgical History:
▫ CABG x 4 (1981)
▫ Tonsillectomy
“Mr. C”
• Comorbidities:
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Coronary Artery Disease (CAD)
Hypertension (HTN)
Diabetes
Degenerative Joint Disease
Chronic Kidney Disease
Chronic Atrial Fibrillation
Previous Stroke (CVA)
Dementia
• Diagnosis:
▫ Ingested foreign object
▫ Congestive Heart Failure (CHF)
 Diastolic: NYHA Class I
 Systolic: NYHA Class IV (Ejection Fraction: 25%)
NYHA Classifications:
NYHA Grading Functional Capacity
Class I:
Asymptomatic
Dysfunction
Class II:
Mild CHF
Class III:
Moderate CHF
Class IV:
Severe CHF
 No limitations
 Ordinary physical activity does not cause
fatigue, dyspnea, or palpitations
 Slight limitations
 Ordinary physical activity results in fatigue,
dyspnea, & palpitations
 Marked limitations
 Less than normal physical activity results in
symptoms
 Unable to carry out any physical activity
w/o discomfort
 Symptoms present @ rest
Physical Therapy Evaluation:
• Prior Level of Function:
▫ Ambulation: RW
▫ 24 hr. care
EVAL
CRITERIA
AROM
• Elderly Mobility Scale:
▫ 10/20
“Patient is borderline in terms of
safe mobility & independence in
ADLs & requires help with some
mobility maneuvers.”
WFL
Shoulder flexion
Hip abduction
• Review of Systems:
▫ Bilateral lower leg edema
(2+)
▫ Breathing discomfort while
supine w/ head of bed down
FINDINGS
PROM
MMT
Generalized
Weakness
Decreased
tolerance for
activity
PT Initial Evaluation: Continued
Bed Mobility:
Rolling L/R
Modified Independence
(HOB raised + Rail utilization)
Balance:
Sitting Static Balance
Good
Sitting Dynamic Balance
Not Tested *
Standing Static Balance
Fair– with Rolling Walker
Standing Balance with Gait
Fair – with Rolling Walker + CGA
HOB: Head of Bed
CGA: Contact Guard Assistance
* Should have been performed
Impairments:
• Edema (2+)
• Pain (2/10)
• Decreased ROM
Right > Left
• Decreased Strength
• Decreased Endurance
Disabilities:
• Decreased
independence with
ADLs
Functional Limitations:
• Decreased
independence
with transfers &
ambulation
Treatment:Ambulation Distance
Day 1
Day 2
Day 3
3/10
2/10
1/10
Therapeutic
- Charleston
600
Exercises in Sitting - Toe Taps
(1 set of 10 reps)
- Heel Taps
500
- Seated Marches
- Long Arc Quads
SAME
SAME
400
Transfers
Minimal Assistance
Sit <-> Stand
x2
With300
Rolling Walker
Minimal Assistance Contact Guard
x2
Assistance x 1
700
Distance (ft.)
Pain (NRPS)
200
Ambulation
100
0
RW: Rolling Walker
+time & verbal cues
+ verbal cues
+ verbal cues
125 ft.
(~38 meters)
300 ft.
(~91 meters)
657 ft.
(~200 meters)
+ RW, CGA,
Verbal Cues
+ RW, CGA,
Verbal Cues
Balance Losses: 2
Balance Losses: 2
Reached 6 min. of
continuous walking
+ RW, CGA
+ 4 Breaks
DayLOBs:
1 Loss of Balances
Day 2
Day 3
Patient-Centered Goals:
Within 7 days, the patient will…
▫ Supine to sit with modified independence
▫ Transfer from bed to chair with minimal
assistance + contact guard assistance while
holding onto rolling walker
▫ Sit to stand with minimal assistance + contact
guard assistance
▫ Ambulate with contact guard assistance +
rolling walker 750 ft. (~228 meters)
PT to see patient 4 x/week
• Treatment Outcomes:
▫ Improving & progressing towards goals
• Prognosis:
▫ Good – Expected to return to previous level of function
 Factors Influencing Rehabilitation Potential:
1. Medical Condition (-)
2. Safety Awareness (-)
3. Age (-)
4. Comorbidities (-)
5. Mental Status (-)
6. 24 hr. care @ home (+)
7. Supportive Wife (+)
Discharge Site: Home Health
Since lives in a 24 hr. care facility
Clinical Question:
Is 6-minute walk test distance a prognostic
indicator for re-hospitalization in elderly male
patients with severe congestive heart failure?
• Important to consider disease severity & hemodynamic
status in CHF patients
• Help identify which CHF patients will likely require
intensive therapy?
 Promote more effective use of therapies
 Help optimize treatment in the CHF population
CHF Statistics:
• Heart failure is the leading cause of
hospitalization among adults > 65 years old
▫ Annually:
> 1 million patients are hospitalized for heart failure
[Medicare Expenditure = $17 billion]
▫ Within 6 Months of Discharge:
> 50% of patients are readmitted to hospital
Article 1:
Prediction of Mortality and Morbidity
With a 6-Minute Walk Test in Patients
With Left Ventricular Dysfunction
Journal of the American Medical Association, 1993
Bittner et al.
Bittner et al.
• Purpose:
▫ To study the potential usefulness of the 6-MWT as
a prognostic indicator in patients with left
ventricular dysfunction
• Methods: Prospective Cohort Study
▫ 898 patients enrolled in the Studies of Left
Ventricular Dysfunction (SOLVD) Registry
 Ejection Fraction < 0.45 (45%) &/or radiological
evidence of CHF
 Ischemic Cause or Hypertensive Cause
▫ 6-MWT performed at baseline
▫ Follow-up Period: 242 days
 Information provided by 895/898 patients
Bittner et al.
Walkers:
N = 833/898 Substudy Patients
Age
60 + 12
Sex (%)
78% males / 22% females
Ejection Fraction (%)
37 + 14
NYHA I (%)
35%
NYHA II (%)
47%
NYHA III (%)
14%
NYHA IV (%)
1%
* Note: Most participants were in LOWER NYHA classifications
Bittner et al.
• Levels:
▫ Level 1:
< 30o meters
▫ Level 2:
30o – 374.9 meters
▫ Level 3:
375 – 449.9 meters
▫ Level 4:
> 450 meters
80%:
Level 1
&
Level 2
While distance was consistent with functional status at the
extremes of the NYHA classification system, this graph
demonstrates a substantial range in the broad class of mild
impairment (NYHA Class II)
Bittner et al.
Note: Hospitalization for any reason &
hospitalization for CHF INCREASED significantly as distance
walked decreased
Performance
Level 1:
MORE total
hospitalizations
MORE
hospitalizations
for CHF
Article 2:
Prognostic Usefulness of the SixMinute Walk in Patients With
Advanced Congestive Heart Failure
Secondary to Ischemic or
Nonischemic Cardiomyopathy
American Journal of Cardiology, 2001
Shah et al.
Shah et al.
• Purpose:
▫ To analyze the ability of the 6-minute walk test
to predict death & hospitalization in patients
with NYHA Class III or IV CHF
• Methods:
▫ 471 patients (initially)  440 patients
 NYHA Class III or IV
 Ejection Fraction <25%
▫ 6-MWT protocol was followed
 Performed at baseline
▫ Follow-up Period: @ 52 weeks
Shah et al.
• Results: How Evaluated?
▫ Cox Proportional-Hazards Model
 Provides an estimate of the hazard ratio &
its confidence interval
 Hazard Ratios:
 The chance of events of a hazard
occurring at a group relative to the other
 Provide confidence in the reliability of the
trial data
Shah et al.
6-Minute Walk Test Baseline Distance:
Baseline 6-MWT Distance
N = 365
Median: 218 meters
Unable to participate in 6-MWT
Default Score: 0 meters
(Too ill to walk)
N = 75
NYHA
HR
SBP
DBP
Shah et al.
Cox Proportional-Hazards Model:
Distance covered on the baseline test significantly
predicted re-hospitalization
0.85/100 m increase
HR
95% CI
Chi Square
p-value
Heart failure patients who increase their walking distance by
100 meters are 0.15 times less likely to be re-admitted to the
hospital (or have a 15% lower risk of re-hospitalization)
Relative Risk Reduction:
1 – (HR)- Δ distance
+100 meters
17.6%
+150 meters
27.6%
+200 meters
38.4%
Shah et al.
365 Baseline Walkers:
• 217/365 hospitalized (60%)
• 252/365 combined endpoint (69%)
Limitations:
Bittner et al.
• Small sample size among NYHA
Class III/IV
Shah et al. & Bittner et al.
• 6-MWT’s performed by a variety of staff members
▫ Reproducibility NOT formally assessed
• Patients only assessed once (at baseline)
• Small percentage of women
▫ May affect generalizability to both genders
• Sub-max Test
▫ Patients DO NOT achieve a peak O2 consumption
▫ Hard to compare to maximal exercise testing
• Assistive devices utilized?
• What were the participants doing between baseline
testing & follow-up?
Conclusions:
Bittner et al.
Shah et al.
• 6-MWT distance strongly & • Baseline distance walked
significantly predicts
independently predicts
hospitalization in patients
hospitalization rates among
with advanced CHF
NYHA Class I & II CHF
patients
• Higher hospitalization
rate during follow-up
• Hospitalization during
▫ Participants had Severe
follow-up was lower
CHF
▫ Fewer severe heart
 EF of 0.25 or less
failure patients
 EF of 0.45 or less
Baseline distance
walked is inversely
related to NYHA Class
How Does This Research Relate to My Patient?
• Article 2 (Shah et al.) relates better to my patient
▫ Mr. C met all inclusion criteria
 NYHA Class III/IV
 Ejection Fraction < 25%
• Mr. C walked 200 meters (657 ft.) in 6 minutes
▫ First Study: Performance Level 1 (< 300 meters)
▫ Second Study: Shy of Median Distance Walked (218
meters)
= His distance walked IS a prognostic
indicator for his risk of re-hospitalization
(Actually re-admitted 3 months after I saw him)
In the Future:
1. Do changes in test performance over a 1-month
period add further prognostic information? If so, what
change from baseline is clinically significant for a
better prognosis?
2. Utilize the 6-MWT to develop/monitor rehabilitation &
progression
3. If a patient is too ill to walk, what else can be used to
determine exercise capacity?
Conclusion:
• Simple, non-invasive method to:
▫ Risk-stratify patients with CHF
• Objective measure to:
▫ Guide clinical judgment & management of CHF
patients
• Safer alternative to cardiopulmonary exercise
testing
▫ Most CHF patients are unable to perform a
maximal symptom-limited exercise test
▫ Correlates better with daily activity effort
References:
• Bittner V, Weiner DH, Yusuf S, Rogers WJ, McIntyre KM, Bangdiwala
SI, et al. Prediction of mortality and morbidity with a 6-minute
walk test in patients with left ventricular dysfunction. SOLVD
Investigators. Jama. 1993;270(14):1702-7.
• Pollentier B, Irons SL, Benedetto CM, Dibenedetto AM, Loton D,
Seyler RD, et al. Examination of the six minute walk test to
determine functional capacity in people with chronic heart failure:
a systematic review. Cardiopulmonary physical therapy journal.
2010;21(1):13-21.
• Shah MR, Hasselblad V, Gheorghiade M, Adams KF, Jr., Swedberg K,
Califf RM, et al. Prognostic usefulness of the six-minute walk in
patients with advanced congestive heart failure secondary to
ischemic or nonischemic cardiomyopathy. The American journal of
cardiology. 2001;88(9):987-93.
Questions?