1. How does distance walked in 6 minutes relate to re-hospitalization?
Congestive Heart Failure (CHF)
in a 79-Year Old Male
Clinical Problem Solving I
Kaylea Kirven
Clinical outcomes = re-hospitalization & mortality

2. Purpose: To describe the physical therapy –
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?
This presentation aims to describe the physical therapy examination, evaluation, plan of care, and outcomes of a patient diagnosed w/ Congestive Heart Failure
It also aims to explore the research related to my prognostic question –
Is 6-minute walk test distance a prognostic indicator of re-hospitalization or mortality in elderly male patients with NYHA Class I - IV congestive heart failure?

3. “Mr. C” 79 year old male Admitted to hospital presenting with:
Abdominal pain
Shortness of breath
Dizziness
Dysphagia
Weight gain of 23 lbs
Past Surgical History:
CABG x 4 (1981)
Tonsillectomy

4. “Mr. C” Comorbidities: Diagnosis: 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%)
Ingested foreign object – model train piece
Presbyesophagus Barium Swallow indicated a wavier rather than straight esophagus. The change can occur with aging
Diet Modification:
Take smaller bites
Chew food longer
Sit in an upright position after meals
NYHA: stands for “New York Heart Association”
Their classification system places heart failure into classes based on functional limitations and severity
Ejection fraction is simply how well your heart is pumping out blood
An ejection fraction of 20 percent means that 20 percent of the total amount of blood in the left ventricle is pushed out with each heartbeat.
A normal heart's ejection fraction may be between 55 and 70 percent.

5. NYHA Classifications:
NYHA Grading
Functional Capacity
Class I:
Asymptomatic Dysfunction
No limitations
Ordinary physical activity does not cause
fatigue, dyspnea, or palpitations
Class II:
Mild CHF
Slight limitations
Ordinary physical activity results in fatigue,
dyspnea, & palpitations
Class III:
Moderate CHF
Marked limitations
Less than normal physical activity results in
symptoms
Class IV:
Severe CHF
Unable to carry out any physical activity
w/o discomfort
Symptoms rest

6. Physical Therapy Evaluation:
EVAL CRITERIA
FINDINGS
AROM
WFL
Shoulder flexion
Hip abduction
PROM
MMT
Generalized Weakness
Decreased tolerance for activity
Prior Level of Function:
Ambulation: RW
24 hr. care
Review of Systems:
Bilateral lower leg edema
(2+)
Breathing discomfort while supine w/ head of bed down
Elderly Mobility Scale:
10/20
“Patient is borderline in terms of safe mobility & independence in ADLs & requires help with some mobility maneuvers.”
MMT & AROM were not specifically tested. They were observed during transfers & bedside exercises
AROM: Right worse than Left for both shoulder flexion & hip abduction
Review of Systems:
Bilateral lower leg edema (2+)
Generalized weakness
Gait disturbance
Dyspnea on exertion
Wheezing with activity
Breathing discomfort (supine & head of bed down)
24 hr. care
- bathing, dressing, cooking as needed

7. 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
Sitting Static Balance: Good – maintains balance w/o support; hands are in lap w/ limited postural sway
Sitting Dynamic Balance: Not tested by my CI ; However, If I were to perform the IE again, I would test since the pt’s static sitting balance was good
Standing Static Balance: Fair – Able to maintain balance w/ RW; Requires occasional min A
Standing Balance with Gait: Fair – Able to maintain balance w/ RW while walking; Requires occasional min A to regain balance after LOBs + CGA (gait belt)
HOB: Head of Bed
CGA: Contact Guard Assistance
* Should have been performed

8. Decreased independence with transfers & ambulation
Impairments:
Functional Limitations:
Edema (2+)
Pain (2/10)
Decreased ROM
Right > Left
Decreased Strength
Decreased Endurance
Decreased independence
with transfers & ambulation
Disabilities:
Decreased independence with ADLs

9. Treatment: Day 1 Day 2 Day 3 Pain (NRPS) 3/10 2/10 1/10
Therapeutic Exercises in Sitting
(1 set of 10 reps)
Charleston
Toe Taps
Heel Taps
Seated Marches
Long Arc Quads
SAME
Transfers
Sit <-> Stand
With Rolling Walker
Minimal Assistance x 2
+time & verbal cues
+ verbal cues
Contact Guard Assistance x 1
Ambulation
125 ft.
(~38 meters)
+ RW, CGA,
Verbal Cues
Balance Losses: 2
300 ft.
(~91 meters)
657 ft.
(~200 meters)
Reached 6 min. of continuous walking
+ RW, CGA
+ 4 Breaks
RW: Rolling Walker LOBs: Loss of Balances

10. PT to see patient 4 x/week
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
Goals are lacking a functional component

11. Discharge Site: Home Health Since lives in a 24 hr. care facility
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. home (+)
7. Supportive Wife (+)
Discharge Site: Home Health
Since lives in a 24 hr. care facility

12. 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
6:16

13. 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

14. 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.

15. Methods: Prospective Cohort Study
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
** Causes of LV dysfunction (Ischemic & hypertensive heart disease) were included due to the multivariate logistic regression
6-MWT Protocol:
30.5 m (100 ft) course is marked by a chair at each end
Pt. is instructed to walk from end to end at own pace, while trying to cover as much ground as possible in the allotted 6 minutes
Every 2 minutes is called out
Encouragement is given every 30 seconds in a standardized fashion – “Keep up the good work/ You’re doing well”
Pt. can stop & rest during the test
At 6 minutes, pt. is instructed to stop walking & the total distance walked is measured to the nearest meter
Recorded Symptoms: angina, dyspnea, fatigue, dizziness, syncope

16. Bittner et al.
Walkers:
N = 833/898 Substudy Patients
Age
Sex (%)
78% males / 22% females
Ejection Fraction (%)
NYHA I (%)
35%
NYHA II (%)
47%
NYHA III (%)
14%
NYHA IV (%) 1%
* Note: Most participants were in LOWER NYHA classifications

17. Bittner et al. Levels: Level 1: < 30o meters Level 2:
80%:
Level 1
& Level 2
This graph is showing the relationship between NYHA class & distance walked among performance levels
Class 1: longer walking distances are evident
Class III/IV: trends for shorter walking distances are evident for
NYHA Class II patients were relatively evenly distributed across the 4 performance level
THUS – while walk-test distance was consistent with functional the extremes of the NYHA classification, it demonstrates a substantial range in the broad class of moderate impairment (NYHA Class II)
More patients in NYHA Class III/IV achieved level 1 & 2 (80% )
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)

18. Bittner et al. Note: Hospitalization for any reason &
hospitalization for CHF INCREASED significantly as distance
walked decreased
Performance Level 1:
MORE total
hospitalizations
MORE
for CHF
Level 1: more total hospitalization & more hospitalizations for CHF

19. Article 2:
Prognostic Usefulness of the Six-Minute Walk in Patients With Advanced Congestive Heart Failure Secondary to Ischemic or Nonischemic Cardiomyopathy
American Journal of Cardiology, 2001
Shah et al.

20. Shah et al. Purpose: Methods:
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 52 weeks

21. Results: How Evaluated?
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
Cox Proportional-Hazards Model
Used to evaluate the relationships b/t 6-MWT & clinical end points before & after adjustment for age, sex, ejection fraction, NYHA class, and etiology of heart failure

22. 6-Minute Walk Test Baseline Distance:
Shah et al.
6-Minute Walk Test Baseline Distance:
Baseline 6-MWT Distance
N = 365
Median: 218 meters
The median distance covered by those who were able to attempt the baseline walk was 218 m
At baseline, 75 (21%) patients received a default score of 0 on the walk test
Default score of 0 = too ill to walk
121 baseline walkers (33%) died before follow-up period
217 baseline walkers (60%) were hospitalized before follow-up
Unable to participate in 6-MWT
N = 75
Default Score: 0 meters
(Too ill to walk)
NYHA HR
SBP
DBP

23. Shah et al.
Cox Proportional-Hazards Model: Distance covered on the baseline test significantly predicted re-hospitalization
0.85/100 m increase
Hazard ratio:
Heart failure patients who increase their walking distance by 100 meters, are .15 times less likely to be re-admitted to the hospital
HR of 1 = no difference
HR < 1 = treatment effective; group of interest has a smaller risk of having the event than the reference group
.85/100-m increase
For every 100 meters covered, there is a 15% reduction in risk of re-hospitalization
Hospitalization risk decreases with more distance walked
Relative Risk Reduction:
1 – (.85) ^ (- change in distance )
A: 6MWT distance longer than patient B by 100 meters is projected to have an event rate (re-hospitalization) ___ % lower than patient B
1- (.85)^-1 = 6.66%
Increase in 6 MWT distance of 100 m would have a relative risk reduction of 6.66%
Increase in 6 MWT distance of 150 m would have a relative risk reduction of 17.2%
Increase in 6 MWT distance of 200 m = 44.4%
Every
HR % 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)

24. Relative Risk Reduction: 1 – (HR)- Δ distance
+100 meters meters meters
17.6% % %

25. 365 Baseline Walkers: Shah et al. 217/365 hospitalized (60%)
252/365 combined endpoint (69%)

26. Limitations: Shah et al. & Bittner et al. 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?

27. Baseline distance walked is inversely related to NYHA Class
Conclusions:
Bittner et al.
Shah et al.
6-MWT distance strongly & independently predicts
hospitalization rates among NYHA Class I & II CHF patients
Hospitalization during follow-up was lower
Fewer severe heart failure patients
EF of 0.45 or less
Baseline distance walked significantly predicts hospitalization in patients with advanced CHF
Higher hospitalization rate during follow-up
Participants had Severe CHF
EF of 0.25 or less
Baseline distance
walked is inversely
related to NYHA Class

28. 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)
13 min.

29. 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?
If too ill to walk, what else can be used????
Shuttle walk test?

30. Conclusion: Simple, non-invasive method to: Objective measure 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

31. 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):
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 ;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):

32. Questions?