Lifestyle Intervention for Heart Failure

Baseline Study Procedures:

If you agree to take part in the pretest portion of this study, your cardiology team will
look at a number of tests performed on your heart as part of your usual care, as well as your
complete medical history, to find out if you are eligible to take part in this study.

If you are found to be eligible to take part in this study, you will be scheduled for a visit
to the Behavioral Research and Treatment Center (BRTC) at MD Anderson.

Before your first visit to the BRTC, you will complete the following tasks at home:

-You will wear an accelerometer to measure your physical activity for 1 week. An
accelerometer is a small device that you wear on your waist during the day. It records how
active you are. You will bring the accelerometer with you when you come for your first visit
in the BRTC.

During your first visit to the BRTC, the following tests and procedures will be performed:

- You will have an electrocardiogram (ECG), which takes about 10 minutes. An ECG is a test
used to measure the electrical activity of the heart.

- You will have your blood pressure and heart rate measured.

- You will complete questionnaires about your symptoms, quality-of-life, psychological
distress, and exercise. These should take about 60 minutes to complete.

- You will complete 2 reaction time tasks on the computer. In one task, you will press a
button on the keyboard to indicate the color of a word on the screen. In the other task,
the computer will present a statement and you will press a button on the keyboard to
indicate whether you think it is true or false. The statements are all opinions. It is
not a test of knowledge. The 2 reaction time tasks together should take a total of about
10 minutes.

- You will do an exercise test on the stationary bicycle. You will ride on the stationary
bicycle for about 10-15 minutes while your heart rate, blood pressure, and breathing are
recorded by certified exercise specialists. While you are pedaling, the difficulty level
will be changed by the study staff. First, you will pedal at a low difficulty level.
After a 5-minute warm up period, the difficulty level will be slowly increased for about
3-5 minutes until you reach the point you cannot continue at that difficulty level.
After that point, the difficulty level will be lowered for about 5 minutes to allow you
to cool down. You can stop the test at any time.

- Then, you will repeat completing the exercise questionnaires and the reaction time tasks
on the computer, which should take about another 10 minutes.

Study Groups:

After the above test and procedures, you will be randomly assigned (as in the flip of a coin)
to be in 1 of 2 groups. You will have an equal chance of being in either group.

If you are in Group 1, you will receive the usual care as provided by the cardiology service,
and a booklet about coping with heart failure. Dietary counseling will be provided once a
month to encourage you to follow to a low sodium diet, with the goal of limiting sodium to 2
grams per day. The dietary counseling will include education about the effects of sodium for
patients with heart failure, sources of sodium in the diet, reading food labels, identifying
low-sodium alternatives to high-sodium foods, and using other types of flavorings rather than
salt and other high-sodium condiments. You will be given the booklet How to Follow a Low
Sodium Diet from the Heart Failure Society of America (appendix S and a copy of the American
Heart Association Low-Salt Cookbook, 3rd edition. If you are a tobacco user or have recently
quit, you will be referred to the MD Anderson Tobacco Treatment program. At the end of 16
weeks, after you have completed your 4 month visit in the BRTC, you will be offered exercise
training described below. If you want to participate in the exercise training, you may do so
at that time.

If you are in Group 2, you will receive all the components of usual care, plus exercise
training.

Exercise Training:

If you are in Group 2, you will visit the BRTC 3 times a week for exercise training. For the
first 12 sessions, you will exercise on a stationary bicycle while your heart rate, ECG, and
blood pressure are recorded.

After the cardiologist finds that you are able to exercise safely, you will use part of the
exercise session to do exercise without having your heart rate, ECG, and blood pressure
recorded. Your exercise sessions at the BRTC will be supervised by a study staff member at
all times. After you have exercised safely for at least 4 weeks, you will begin at-home
exercise program, which will be a series of exercises developed individually for you, in
addition to the supervised exercise sessions in the BRTC. You will be given an exercise log
to describe your at-home exercise, and any problems or symptoms you experience during or
after the at-home exercise sessions.

The visits to the BRTC for exercise training will last about 1 hour. You will come to the
BRTC for these visits 3 times a week for 16 weeks.

If you are in Group 1, you have the option of choosing the exercise training described above
or a 12-week home-based exercise training program that you will start after your 4 - month
visit to the BRTC. You will be scheduled for an in-person exercise session with the exercise
physiologist at the BRTC at MD Anderson. During this visit, you will receive instructions on
how to complete your exercise sessions safely and effectively at home. This visit will take
about 1 hour to complete. You will be provided with an exercise recommendation that will help
you work up to 30 minutes of exercise, at least 3 times a week.

The exercise physiologist will call you once a week for 12 weeks to check on your progress
and answer any questions you may have about your exercise program. You will also have the
opportunity to come back to MD Anderson up to 1 time a week if you would like help from the
exercise physiologist.

You will be given a pedometer to wear. A pedometer is a small device (about the size of a
deck of cards) that is worn on the belt and measures the number of steps you take each day.
You will record the number of steps and minutes of exercise for each day on an exercise log
sheet.

At Weeks 4 and 8 (+/- 7 days), you will have a telephone interview about any side effects you
may be having and how well you are able to function in daily activities.

You will also be counseled on limiting how much sodium you consume. The dietary counseling
will include education about the effects of sodium on patients with heart failure, sources of
sodium in the diet, reading food labels, identifying low-sodium alternatives to high-sodium
foods, and using other types of flavorings rather than salt and other high-sodium condiments.

These calls should take about 45 minutes.

Follow-Up Visits:

If you are in either Group 1 or Group 2, you will have an appointment with the MD Anderson
cardiology team 4 months from the baseline assessment. At this visit you will be asked about
your symptoms. Blood (about 1 teaspoon) will be drawn to measure biomarkers at baseline and
at the 4 month visit. Biomarkers are chemical "markers" in the blood that may be related to
your heart failure.

If you are in Group 1 or Group 2, you will have a follow-up visit in the BRTC about 16-18
weeks after your baseline visit.

Ten (10) days before this visit, you will receive a new accelerometer in the mail. You will
be called and reminded to wear the accelerometer. You will wear the accelerometer for 7 days
and then bring it to the last visit to the BRTC.

At your last follow up visit to the BRTC, the following tests and procedures will be
performed:

- You will complete questionnaires about your symptoms, quality of life, psychological
distress, and exercise.

- You will complete 2 reaction time tasks on the computer.

- After these questionnaires and reaction tests, you will have an ECG and your blood
pressure and heart rate will be measured.

- You will have an echocardiogram.

- You will then do an exercise test on the stationary bicycle.

- Then you will repeat the exercise questionnaires and the reaction time tasks on the
computer.

- You will also be asked to take part in an interview about what you thought of the
exercise program and the tasks you performed at home. This interview should take about
15 minutes.

After your 16-week visit, information about your cardiac tests, health problems, and
hospitalizations will be collected from your medical record.

Participants in the waiting list group who choose to participate in the exercise program
after their 16 week assessment will complete questionnaires once a month to measure symptoms.
After 4 months of exercise (3 months for home-based) they will repeat all the follow-up tests
described above.

This is an investigational study.

Up to 80 participants will be take part in this study. All will be enrolled at MD Anderson.

Inclusion Criteria:

1. diagnosis of NYHA I, II or III heart failure (as identified by any of the following
physical findings of heart failure (jugular venous distension, crackles, edema, S3);
pulmonary edema on chest x-ray; BNP > 100 pg/ml; or at least two of the following
symptoms: paroxysmal nocturnal dyspnea, shortness of breath, swelling, fatigue;

2. previous chemotherapy that contributed to the development of heart failure (i.e.,
heart failure develops or worsens after receiving chemotherapy, with no other obvious
explanation);

3. oriented to person, place, and time;

4. living in the Houston area (Harris county or a contiguous county), or planning to stay
in the area for at least the next 16 weeks.

5. 18 years of age or older.

6. diagnosis of cancer

7. have completed treatment, or are on long-term adjuvant or maintenance chemotherapy
only

Exclusion Criteria:

1. remain in NYHA class IV heart failure despite therapy;

2. have health problems or current treatments that would make exercise unsafe, as
determined by the cardiologist;

3. cannot provide informed consent;