The HF-Wii study: Improving exercise capacity of patients with heart failure through exergaming: Secondary outcomes and per protocol analysis of an international multicenter RCT

//Presented at ESC Heart Failure 2018 in Vienna, Austria, by Tiny Jaarsma (Linkoping, Sweden) //

Introduction and methods

Heart failure (HF) guidelines recommend regular exercise, but adherence to doctor’s advice to exercise is generally low, as is daily physical activity in HF patients. As for some patients, it may be difficult to start exercising in conventional ways, ‘exergaming’ is being explored as a tool in rehabilitation. Exergaming refers to the playing of video games that require rigorous physical exercise; the game is intended as a work-out. It involves technology-driven game playing, and uses technology that tracks body movement or reactions. It is thought that through various positive assets of exergaming (challenge, performance, feedback, enjoyment and convenience), motivation, physical activity and self-efficacy may improve and lead to better health behavior, which may ultimately improve exercise capacity and health.

Pilot testing of exergaming with the commercial Wii system was promising in HF patients, but its effectiveness has not been tested. The objective of the HF-Wii study was therefore to determine the effects of structured access to an exergame on exercise capacity and the level of physical activity in patients with HF. In an international (6 countries) multicenter RCT, 605 patients with HF independent of LVEF or NYHA functional class were randomized 1:1 to either motivational support only (controls) or to structured access to an exergame with blinded assessment of the primary endpoint (6-minute walking test: 6MWT). The activity advice was to be active for 30 minutes per day. The current analyses focus on the effects on well-being, health-related quality of life (HR-QoL), symptoms of anxiety and depression, as well as if the amount of time spent exergaming was related to outcomes.

Main results

• At 3 months, a clinically and statistically significant improvement was seen in the 6MWT, of 33 meters, in the exergaming group (n=242) as compared with controls (n=244).
• No difference was seen between groups in the number of people who improved and who decreased meters walked.
• Of secondary outcomes at 3 months, the current well-being was significantly better in the exergame group (Ladder of life score: 6.6 vs. 6.2, P<0.05), as was expected well being (score 7.6 vs. 7.4, P<0.05).
• No significant differences were seen in the Minnesota Living with HF scale, with regard to total, physical or emotional scores, nor in scores for anxiety or depression.
• 17% of patients in the exergame group never played, thus had adherence of 0%. 50% of patient played with adherence >60%, and 45% played >80%.
• When relating the gain in 6MWT-meters to the level of adherence, no clear cut-off level of adherence could be discerned.

Conclusions

This is the first large scaled and adequately powered study that evaluated the effectiveness of exergaming in HF patients to show significant effects on exercise capacity and well-being. Exergaming was safe and feasible in HF patients with different patient profiles, in different health care systems, cultures and climate challenges. Only few people dropped out due to the intervention, and half of the patients assigned to exergaming adhered to the advice of 30 minutes exercise per day for at least 60%. Secondary outcomes other than current and expected well-being were not significantly affected. The benefit seen in some patients could not solely be explained by the amount of time they played. Thus, further analysis is needed to explore the success factors, to identify which patients may be most likely to benefit, and the long term effects.

Discussion

The discussant L.M. Hill (Co.Antrim, UK) noted that it was a clear strength of the study that the diagnosis of HF was independent of left ventricular function. The fact that only 44 patients dropped out, underscores the feasibility of this intervention. However, the results were modest. However, in some patients the results were good. It will be interesting to find out longer term results. It is striking that many people were screened (2099), and only 605 randomized. Jaarsma replied that this was not because people did not want to exercise, but more so because they did not want extra follow-up visits and the associated travel and time burden. It is also important to realize that this type of intervention is likely not suitable for all, thus it is important to look for those patients who may be suitable for it, and who will benefit from it.

Our reporting is based on the information provided at the ESC Heart Failure 2018 congress