About the REACH-HF trial
In our main multicentre trial the inclusion criteria were:
- Adults (aged ≥18 years).
- Patients who have a confirmed diagnosis of systolic heart failure (HF) on echocardiography (ie, left ventricular ejection fraction <45% within the past 5 years).
- Patients who have experienced no deterioration of HF symptoms in the past 2 weeks resulting in hospitalisation or alteration of HF medication
You will find the full list of exclusion criteria is listed under Table 1 in our protocol paper: https://bmjopen.bmj.com/content/5/12/e009994
So our evidence is based on these criteria. We also have feasibility data on patients with HFpEF (EF >45%) but in only 50 patients : https://bmjopen.bmj.com/content/8/4/e019649
REACH-HF Trainee Enquires
Thank you for your enquiry and interest in REACH-HF!
REACH-HF is a comprehensive 12 week home-based, health professional facilitated cardiac rehabilitation programme for patients with Heart Failure.
It includes a patient manual, progress tracker, exercises (chair based and walking), carers’ manual and relaxation.
The REACH-HF Service Delivery Guide has more information. You may access it from the REACH-HF website: http://sites.exeter.ac.uk/reach-hf/reach-hf-service-delivery-guide/
Apart from the main RCT trial, we have also delivered a pilot roll out of REACH-HF at four NHS cardiac rehab centres (Beacon sites – Gloucestershire, Belfast, Wirral, and University College Hospital, London) in 2019-20. Funding from Heart Research UK is enabling us to evaluate the delivery of REACH HF across four health boards in Scotland in 2021. In response to COVID-19, we provided a 2-day online training to nearly 90 health care professionals (cardiac rehab nurses, HF specialist nurses, exercise physiologists and others) from across the UK in 2020. Some of these have started delivering REACH HF and hope to continue through the pandemic and beyond. The online training courses are continuing and available through the Heart Manual Department or telephone on 0131 537 9127/9137 for dates in 2021.
The costs of REACH HF facilitator training by the Heart Manual Department are: £200 per participant attending the 2 day remotely delivered course plus a minimum purchase of 10 REACH HF intervention packs/ HF Manuals each @£30 per pack/HF Manual=£300, (including delivery) therefore a total cost of £500 per participant.
The Wirral Community Cardiovascular Rehabilitation Beacon site staff are happy to speak to interested cardiac rehab teams on their experience of the ‘real-life’ rollout of the programme. For more details please see: https://www.nice.org.uk/sharedlearning/delivering-rehabilitation-enablement-in-chronic-heart-failure-reach-hf-in-wirral
Please do contact us () if you have any further queries or if you are interested in adopting REACH-HF in your area.
Further information on REACH HF is also available from the NICE shared learning website: https://www.nice.org.uk/sharedlearning/covid-19-ready-rehabilitation-for-heart-failure-reach-hf-can-deliver
Q. One of my staff Cardiac specialist nurse was unable to attend this training due to leave. Are we able to cascade the training to them in order for them to facilitate with our exercise physio who is on the course today to facilitate with their patients?
A:The REACH-HF developers do not recommend facilitation of the REACH-HF manual without training or cascading of the facilitator training within services.
As per conventional cardiac rehab (CR) programmes there is a need to ensure that REACH-HF is supported by a multidisciplinary CR programme. REACH-HF Facilitators should be part of a wider multidisciplinary team organising the clinical care and cardiac rehabilitation /self-care support for the patient. This may include referring on to specialist (eg. psychological counselling, or specialist exercise / physiotherapy advice) as part of the core team or through an agreed referral pathway.
Having a co-attendee, trainee or supervisor at home visits/on site is also acceptable as long as one person (the facilitator) has been trained in the delivery of the REACH-HF programme (although we don’t believe it is necessary to have two staff present).
How we deliver elements of the REACH-HF programme
|Chair based exercise programme (CBE)||Walking Programme (WP)|
|Duration (support by facilitators)||10-12 weeks||10-12 weeks|
|2-3 days/week||Progress to 3-4 days/week|
|Range 13-40 mins
Level 1 ~ 13 mins includes warm up (WU) and cool down (CD) only *
Level 2 ~ 21 mins (6 mins WU & CD)
Level 3 ~ 21 mins (6 mins WU & CD)
Level 4 ~ 25 mins (6 mins WU & CD)
Level 5~ 28 mins (7 mins WU & CD)
Level 6 ~ 30 mins (7 mins WU & CD)
Level 7 ~ 38 mins (7 mins WU & CD)
|Progress to 20-30 mins (with additional 3-5 mins warm up/cool down)
Level 1: 5-10 minutes
Level 2: 10-15 minutes
Level 3: ≥20 minutes
The initial exercise training intensity is in the range of 40% to 70% of a patient’s capacity. This is ideally based on incremental shuttle walk test (ISWT) or 6-minute walk test (6MWT) calculated metabolic equivalents (METs) prior to commencing the core exercise training component.
Each of the seven CBE levels has a known METs value which aligns with roughly 70% of the mean METs score derived from the ISWT and 6MWT. The CBE programme has built in (on screen) pacing and quality assurance of movement (video narrative).
The initial exercise training intensity is in the range of 40% to 70% of a patient’s capacity. This is ideally based on ISWT or 6MWT calculated METs prior to commencing the core exercise training component.
Each prescribed walking level is based on walk test distances or speeds with goals tailored to patient preferences.
|The allocated CBE level or WP pace or distance is validated by facilitators through
(1) subjective checks using patient sensations (“make you breathe heavier, feel warmer and have a slightly faster heartbeat, but you should still be able to talk”) and
(2) Use of the REACH-HF manual tracker (0 to 10) effort scale where zero ~ no significant effort in carrying out the task to 10 representing excessive effort that is very difficult to maintain. Patients with facilitators are encouraged to understand and gain experience of the effort scale and try to avoid too many occasions where patients go above a rating scale 7 on the effort scale. If the effort required during a period of sustained exercise (e.g. 3 or more mins) is rated as 8 or above then the next exercise period (intensity level) should be adjusted down to a lower level.
|*Although the CBE has a defined warm up period of 6 to 7 mins per session all exercises in the main part of each CBE level are also steadily progressive allowing the muscles, joints and physiological responses to adapt with each minute of the exercise.|
Q: The warm up for the chair based exercise is 5 minutes long and grants the required cardiac response pre-exercise. I wondered how this was achieved due to BACPR standards for the warm-up being 15 minutes to achieve the required cardiac response.
A: Most studies show that 5 to ten minutes is sufficient to achieve a warm up before commencing moderate levels of exertion. The higher the intensity the more warm up is required with 15 mins seen as optimal to help prepare healthy people and fitter patients to exercise at higher intensities.
In heart failure the situation is slightly different especially for those with lower levels of fitness and multiple comorbidities.
One of the challenges in managing exercise training in heart failure is to do enough exercise to help maintain fitness (which we know drops rapidly over time in this group) and to do so without exhausting patients. As a context the mean age of REACH-HF patients is over 70 years with an average of three additional comorbidities which means we are primarily setting exercise goals around maintenance of fitness.
With that context in mind most guidelines suggest shorter duration warm up for instance the ACPICR and EPG state in their guidance that it should be reduced in proportion to the main conditioning phase duration and expected intensity (see below). https://www.acpicr.com/publications/healthcare-professionals/
In respect of REACH-HF and chair based exercise (CBE) we have a built in warm-up before the main part. On top of that the main part of the CBE is also incremental in that minute-by-minute each set of exercise requires slightly more range of movement, co-ordination and repetitions with an aim to achieve an optimal level of exercise stimulus towards the end of the main period of the exercise training during each session. In summary the main part of our CBE programme incorporates increments of demand which continue to prepare the individual for the next level of exercise during each session.
The added value of the REACH-HF approach to warm-up is that our clinical trial showed no adverse events related to exercise and feedback from patients was strongly positive.
Q: On the exercise component I noticed our Met values varied to ones printed in the document? I have attached our Incremental Shuttle Walk test to compare. I’m only querying this as I had a discussion with someone on the course about this and we were using different Met levels.
A: METs is murky water and estimates of METs even more so!
Measured METs per task will vary based on the point of reference during the task being measured.
For instance you would normally want to record the MET cost of an activity based on at least three minutes of activity at a particular level (often referred to as steady state).
Once you have the three minutes of data there's a dilemma: do you take the 1st, 2nd or 3rd minute value as your MET cost?
Or do you take the middle value or end value or the average of the three minutes?
You could - and many do - just take the peak MET value even if it's for less than one minute irrespective of where it occurs in the data timeline. All of these approaches lead to different MET values for the same task. This type of variation also leads to confusion in the literature.
There's possibly no right or wrong way but what is important is that people who produce MET tables state if their numbers are based on average or peak values. In REACH-HF we use average MET values related to the ISWT levels. If studies use peak values they will always produce higher METs per level than average MET values.
The other dilemma we have when using METS is the assumption that 1 MET = 3.5 ml 02/kg/min). This was calculated based on a 70kg person which doesn't resonate with many of our patients. To counter the impact of an 'estimate within an estimate the more scientifically orientated researchers (JB being one of them) directly measure resting metabolic rates (resting METs) for the actual individual. They are then able to divide the peak or average METs for a task by the individual's actual resting METs. It's good science but can't be done on mass in patient populations.
When you look at the array of MET values in the numerous tables that exist it's often the above permutations/approaches that can explain the differences.
In summary: ISWT MET values based on direct measurement (as outlined above) can lead to different values (mean vs peak). Estimated METs derived from average walking speed MET equations are at best a good guess but not even close to being accurate.
Thankfully, we have our clinical skills and judgement to work around these uncertainties.