Executive Summary
Heart failure management with a function-first lens
Heart failure is a common cause of hospitalization worldwide. Despite advances in medical therapy, readmissions remain frequent and functional decline is often substantial. Routine assessment frequently emphasizes ejection fraction (EF) and symptom severity (NYHA class). The Short Physical Performance Battery (SPPB) captures real-world functional performance and can provide prognostic information related to readmission and mortality, while also supporting structured tracking in Cardiopulmonary Recovery.
Typical functional focus
- Severity classification based on EF
- NYHA functional class (I–IV)
- BNP/NT-proBNP tracking
Strategic shift
- Quantified functional performance
- Earlier identification of high-risk patients
- Objective tracking of recovery response
Why function should be assessed alongside cardiac markers in heart failure
A vicious cycle of exercise intolerance and functional decline
Reduced cardiac output can limit skeletal muscle perfusion, contributing to exercise intolerance. This may progress to reduced activity, muscle loss, and further functional decline.
Limitations of NYHA classification
NYHA class relies heavily on subjective symptom reporting and can vary across assessors. Patients with the same NYHA class may have markedly different functional performance.
An independent prognostic indicator
SPPB scores can be associated with readmission, mortality, and quality-of-life outcomes in heart failure, providing a quantitative view of functional vulnerability that conventional markers may miss.
Evidence-focused data in heart failure populations
2.1 SPPB and readmission risk
low function (SPPB < 7)
In some hospitalized heart failure cohorts, approximately 40% of patients fall below an SPPB score of 7. This low-function group has shown higher early readmission risk compared with higher-function groups.
Association with length of stay
Lower SPPB scores have been associated with longer hospital stays and a higher likelihood of post-discharge care needs.
Reference: Pulignano et al., Eur J Heart Fail.
2.2 One-year readmission by SPPB tier
Readmission rates tend to increase as SPPB scores decline. Visualization based on multicenter cohort-style reporting.
Functional note: patients with SPPB below 7 may experience substantially higher readmission rates than those with high function.
Why SPPB tracking matters in Cardiopulmonary Recovery
| Stage | Key point | Practical note |
|---|---|---|
| Pre-rehab assessment | Baseline SPPB helps identify functional vulnerability and set patient-specific goals. | Supports earlier identification of higher-risk patients |
| Outcome reporting | Post-program reassessment provides an objective, repeatable functional outcome measure. | Complements 6MWT and peak VO₂ reporting |
| Exercise prescription | SPPB tiers can guide individualized exercise intensity to reduce adverse events. | Lower scores may warrant lower initial intensity and closer follow-up |
Risk when SPPB is not measured
- Over-prescription of intensity in vulnerable patients may increase fall or arrhythmia risk
- Outcomes become harder to demonstrate objectively when relying only on symptoms
Rehab management using the SPPB
- Individualized exercise planning aligned with functional deficits
- Quantified outcomes that strengthen multidisciplinary communication and reporting
Practical functional staging in heart failure
A pragmatic, SPPB-based tiering approach to support recovery planning
Heart failure population
Applicable to both HFrEF and HFpEF
SPPB (gait speed + balance + chair stands)
10–12
Standard rehab intensity
Reassess every 6 months
7–9
Moderate intensity
Reassess every 3 months
< 7
Lower initial intensity
Monthly follow-up
Management principles for SPPB < 7
Start with lower-intensity aerobic training (for example, RPE 10–12) alongside lower-limb strengthening. Provide fall-prevention education and reassess regularly to monitor functional trajectory.
Special consideration for HFpEF
Patients with HFpEF can have low SPPB despite preserved EF. Selecting recovery intensity based on EF alone, without functional assessment, can be inappropriate.
Practical implications
Key practical takeaways
① Baseline SPPB during hospitalization
Measuring baseline SPPB can help identify higher-risk patients early and support discharge planning with targeted recovery strategies.
② Regular reassessment in outpatient follow-up
Periodic SPPB assessment can detect functional decline earlier than rehospitalization, enabling proactive intervention.
③ Include SPPB in rehab outcome reporting
Reporting SPPB alongside 6MWT and peak VO₂ can provide a multidimensional view of functional status.
④ Discharge planning and post-acute linkage
For low-function patients, reassess the safety of returning home and consider referral to outpatient Cardiopulmonary Recovery or Physical Medicine.
AndanteFit – Selected Reference Institutions
- Wonju Severance Christian Hospital / Severance Hospital
- Samsung Medical Center / Seoul St. Mary’s Hospital
- Korea University Guro Hospital / Korea University Anam Hospital
- Pusan National University Hospital / Pusan National University Yangsan Hospital
- Chonnam National University Hospital / Chungnam National University Hospital / Chungbuk National University Hospital
- Keimyung University Dongsan Hospital / Kyungpook National University Hospital / Inha University Hospital / Hanyang University Hospital
- Gachon University Gil Medical Center (Physical Medicine) / Senri Hospital (Japan)
- Juntendo University / Kanazawa University (Japan)
Selected references
- 1. Pulignano G, et al. Eur J Heart Fail. SPPB as a predictor of outcomes in patients with heart failure.
- 2. Volpato S, et al. J Am Geriatr Soc. Physical performance measures and mortality in older adults with heart failure.
- 3. Kitzman DW, et al. JAMA. Exercise training in HFpEF and functional outcomes.
- 4. HF-ACTION Trial. Circulation. Effects of exercise training on outcomes in patients with heart failure.
- 5. ESC Guidelines 2021. Diagnosis and treatment of acute and chronic heart failure.
- 6. Korean Society of Cardiology. Practice guideline for cardiac recovery, 2023.