Cardiac Rehabilitation in Heart Failure after the Extramatch II Study: Who Still Believes?

The ExTraMATCH II meta-analysis published in this Journal,1 mainly driven by the results of the large HF-ACTION trial,2 found no impact of exercise-based cardiac rehabilitation (ExCR) in patients with heart failure with reduced ejection fraction (HFrEF) on mortality or hospitalization, when compared to no exercise control. As a consequence, one could argue that in the modern era of cardioprotective drugs and implantable devices, ExCR might be of lesser utility. Indeed, in our opinion, this study emphasizes the potential role of ExCR in heart failure patients, when provided with adaptations. Primary endpoints failed in the whole ExTraMATCH II patient population, but ExCR positively affected mortality in elderly and ischaemic patients, as far as all-cause hospitalization improved in those with lower exercise tolerance. Well, then, ExCR programmes in routine practice should give priority to these patients, though generating more complex and expensive pathways of care due to advanced co-morbidities, elevated disability, and frailty. Moreover, ExCR core components should not be underpowered, as highlighted from trials included in the ExTraMATCH II meta-analysis, in which exercise intervention only accounted for about one third of all programmes. After ExTraMATCH II, further research should broaden the usual investigation of a stable, mostly in New York Heart Association class II, HFrEF, ambulatory, ‘HF-ACTION-like’ patient, largely represented in current series. We need now to turn our attention to the often precociously discharged patient after an episode of acute decompensation, who is at increased risk of becoming the ‘tomorrow frequent flyer’ to emergency rooms due to heart failure exacerbations. We already have some embryonic evidence about the positive effect of ExCR in this vulnerable phase. The Lombardy Region of Italy is characterized by a large (more than 50 facilities) cardiac rehabilitation network, strongly connected to acute cardiac wards: in this favourable scenario, according to administrative data collected on more than 140 000 heart failure cases from 2005 to 2012 (therefore in the modern era), patients actively referred to cardiac rehabilitation after hospitalization in acute care had lower mortality and readmission rates, which decreased by 43% and 31%, respectively, as compared to patients who were not referred.3 What are these impressive numbers from the real world telling us, obviously keeping in mind several confounding aspects? Too good to be true? Or, rather, ExCR in heart failure could work best — if best arranged — right when offered to vulnerable, high-risk patients? On this basis, further research is needed and a third ExTraMATCH between ExCR and usual care would not be just pointless.