"Most inactive in my life": patient-reported barriers to cardiac rehabilitation in heart failure.

Background & Objective. Cardiac rehabilitation is an existing guideline-concordant intervention for heart failure that provides benefits but is grossly underutilized by both physicians and patients. We aimed to identify patient-reported barriers and facilitators of participation in cardiac rehabilitation. Design, participants, approach: Qualitative theory-guided in-depth interviews were conducted with adults with heart failure, recruited from ambulatory settings with oversampling of those with heart failure with preserved ejection fraction. Thematic analysis was applied to interview data. Depressive symptoms and perceived stress were assessed by Patient Health Questionnaire (PHQ-8) and Perceived Stress Scale (PSS), respectively. Key results: Twenty-two adults with heart failure, aged 27-85, completed the study; of them 59.1% were women, 68.2% - African American, 4.5% - Hispanic; 77.3% had public insurance or were self-pay; 68.2% had heart failure with preserved ejection fraction. Mean PHQ-8 score was 11.4 (SD= 2.9) and mean PSS score - 20.4 (SD=4.5). Patient-reported barriers to cardiac rehabilitation included unawareness of cardiac rehabilitation and its benefits, perceived inability to exercise, depression, and weight gain, specifically for heart failure with preserved ejection fraction. Perceived inability to exercise stemmed from uncontrolled heart failure symptom burden and exercise intolerance, medication side effects, non-cardiac pain, fear of exercise, and low motivation for exercise. Facilitators of participation included intrinsic and extrinsic motivating factors and specific features of programs, such as individualized and supervised interventions with moderate level of exercise. Conclusion: Participants reported multiple barriers to cardiac rehabilitation; some of them can be modified by providing counselling and referral to cardiac rehabilitation from primary care physicians and simultaneously addressing heart failure symptom burden, pain, stress and depression. Combining cardiac rehabilitation and weight management can benefit adults with heart failure with preserved ejection fraction specifically. Increasing insurance coverage for cardiac rehabilitation for heart failure is warranted.