Demand for exercise training in patients with pulmonary arterial hypertension in Scotland
- Alison MacKenzie⇑ and
- Martin Johnson
- Alison MacKenzie, Scottish Pulmonary Vascular Unit, Glasgow, UK. E-mail: alisonmackenzie2{at}nhs.net
Abstract
Scottish patients with PAH wish to take part in dedicated and intensive exercise rehabilitation programmes http://ow.ly/Owwai
To the Editor:
Despite significant advances in medical therapy, most patients with pulmonary arterial hypertension (PAH) remain symptomatic on treatment [1]. The recently published UK PAH national audit 2014 [2] demonstrates a 65% rate of failure of monotherapy at 2 years. New treatment strategies are therefore essential to improve morbidity and, if possible, mortality.
Over the past 10 years, the body of evidence supporting exercise training as an effective treatment for PAH has grown significantly, such that the 2013 consensus statement on the management of PAH upgraded its recommendation to class I, level A. This has been reinforced recently in a detailed review from the Heidelberg group which summarised the evidence for this intervention [3].
The consensus statement and review recommended that exercise training of PAH patients should be undertaken by centres experienced in both the management of PAH and rehabilitation of compromised patients. Despite this, dedicated exercise training programmes do not exist in the UK and many other European countries. In these countries, exercise training is delivered to a small, unselected population of pulmonary hypertension patients in an ad hoc manner, by services specialised for chronic obstructive pulmonary disease or left heart failure.
Several factors may hinder the widespread adoption of specialised exercise training for patients with PAH. First, the infrastructure and expertise that exists in German rehabilitation clinics, where much of this research has been conducted, does not exist in many other centres, raising the question of whether these results can be replicated elsewhere. Secondly, the successful approach described by Mereles et al. [4] involved an initial intense inpatient phase followed by a monitored outpatient period, using multimodality, PAH specific rehabilitation. Such an approach is demanding both on patient time and hospital resources. The optimal structure for a rehabilitation programme has not been established and other investigators have evaluated less intensive strategies. De Man et al. [5] utilised existing outpatient cardiac rehabilitation facilities and observed improved muscle endurance but failed to show an improvement in 6-min walk distance (6MWD), suggesting that there are advantages to the inpatient approach. Finally, no long-term data exist to support a prognostic benefit.
In order to establish a training programme for PAH, it must first be determined that there is demand among the patient population for such a treatment. With this in mind, we surveyed patient interest and willingness to participate in a programme of intensive inpatient rehabilitation, followed by outpatient rehabilitation, mirroring that of Mereles et al. [4].
The Scottish Pulmonary Vascular Unit (SPVU) in Glasgow, UK serves a population of 5.3 million and is the national referral centre for PAH in Scotland, with a prevalent population of 47 per million [2].
In our cohort, we contacted 224 patients with PAH. We included the following patients: 1) World Health Organization functional class I−III; 2) 6MWD ≥150 m; and 3) PAH diagnosed by right heart catheterisation (mean pulmonary artery pressure ≥25 mmHg, pulmonary capillary wedge pressure ≤15 mmHg and pulmonary vascular resistance >3 Wood units).
43% of patients (96 out of 224) responded to the survey. 62.5% (60 out of 96) were interested in all components of the rehabilitation programme (inpatient and outpatient); a further 11.5% (11 out of 96) were interested in outpatient rehabilitation only.
Those interested tended to be younger and were in a better functional class. There was no significant difference between groups in haemodynamics, quality of life or N-terminal pro-brain natriuretic peptide (table 1).
Additionally, patients provided free text responses. Many reported enthusiasm towards the proposal and felt it would improve their confidence, overall health and quality of life. The following reasons were cited in patients who felt at least one aspect of the programme would be unsuitable: 1) too far from home, 19.4% (seven out of 36); 2) work or carer commitment, 27.8% (10 out of 36); 3) too old or too many comorbidities, 27.8% (10 out of 36); 4) too big a time commitment, 5.6% (two out of 36); 5) active enough, 8.3% (three out of 36); 6) equipment in their house would be unacceptable, 2.8% (one out of 36); and 7) no reason given, 8.3% (three out of 36).
Our data demonstrate considerable enthusiasm to pursue exercise training as a treatment, even when it involves an inpatient stay. This level of interest, in addition to the growing body of evidence supporting the beneficial effects of exercise, suggests that strong consideration should be given to establishing access for all patients with PAH to dedicated rehabilitation services as a routine element of their care.
In our population, those with poorer functional class or significant comorbidity were less likely to participate in rehabilitation. Even in patients with severe PAH, exercise training is safe and beneficial. A concerted effort must be made to ensure patients with a higher burden of disease are reassured and efforts are made from a logistical and rehabilitation perspective to make such an intervention more acceptable. This requires further research to establish the optimal components of a PAH rehabilitation programme and how it might be successfully modified for more compromised individuals.
Footnotes
Conflict of interest: Disclosures can be found alongside the online version of this article at erj.ersjournals.com
- Received May 7, 2015.
- Accepted May 28, 2015.
- Copyright ©ERS 2015