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Cardiac Rehabilitation November 1st, 2007

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Title: Cardiac Rehabilitation November 1st, 2007


1
Cardiac RehabilitationNovember 1st, 2007
  • Jeffrey Marogil, MD
  • UIC Cardiology

2
(No Transcript)
3
Introduction
  • Up until the 1950s, strict bed rest was thought
    to be the best medicine after a heart attack.
  • Following discharge moderately stressful activity
    such as climbing stairs was discouraged for a
    year or more.

4
Introduction
  • "The patient is to be guarded by day and night
    nursing and helped in every way to avoid
    voluntary movement or effort."
  • Thomas Lewis, 1933

5
Introduction
  • Despite the known benefits of cardiac
    rehabilitation (CR) and widespread endorsement
    (CR) is vastly underutilized and less than 30 of
    patients participate in CR programs after a CV
    event.

6
Overview
  • What is cardiac rehab
  • Components, Terminology Contraindication
  • Safety
  • Medicare Coverage
  • Evidence
  • STEMI UA/NSTEMI
  • Stable angina Percutaneous coronary
    intervention
  • Coronary bypass surgery
  • Heart failure
  • Rehab Options at UIC and in IL
  • Conclusions

7
What is Cardiac Rehab?
8
Definition
  • Cardiac rehabilitations services are
    comprehensive, long-term programs involving
  • medical evaluation,
  • prescribed exercise,
  • cardiac risk factor modification,
  • educations and counseling.
  • These programs are designed to limit the
  • physiologic and psychological effects of cardiac
    illness,
  • reduce the risk for sudden death or
    reinfacrction,
  • control cardiac symptoms, stabilize or reverse
    the atherosclerotic process,
  • and enhance the psychosocial and vocational
    status of selected patients

9
  • 2007 American Association of Cardiovascular and
    Pulmonary Rehabilitation/AHA/ACC Guidelines
  • Performance Measures on Cardiac Rehabilitation
    for Referral to and Delivery of Cardiac
    Rehabilitation/Secondary Prevention Services
  •  J Am Coll Cardiol 2007501400-33

10
Cardiac Rehab Terminology
  • Phase 1 Inpatient Rehab - A program that
    delivers preventive and rehabilitative services
    to hospitalized patients following an index CVD
    event
  • Phase II Early outpatient CR - a programmed that
    delivers preventive and rehabilitative services
    to patients in the outpatient setting early after
    CVD event within the first 3-6 months and
    continuing for up to 1 year
  • Phase III Long-term outpatient CR - Longer term
    delivery or preventive and rehab

11
Cardiac Rehab Terminology
  • Risk Stratification for Exercise
  • Class A
  • Class B
  • Class C
  • Class D
  • Guidelines published by the American Heart
    Association use four categories of risk according
    to clinical characteristics

12
Cardiac Rehab Terminology
  • Class A apparently healthy and no clinical
    evidence of increased cardiovascular risk of
    exercise.
  • Class B established CHD that is clinically
    stable. Overall low risk of cardiovascular
    complications of vigorous exercise.
  • Guidelines published by the American Heart
    Association use four categories of risk according
    to clinical characteristics

13
Cardiac Rehab Terminology
  • Class C moderate or high risk of cardiac
    complications (multiple myocardial infarctions or
    cardiac arrest, NYHA class III or IV, Exercise
    capacity of the exercise test.
  • Class D unstable disease for whom exercise is
    contraindicated.
  • Guidelines published by the American Heart
    Association use four categories of risk according
    to clinical characteristics

14
Absolute Contraindication to Exercise
  • Absolute Acute myocardial infarction (within two
    days)
  • Unstable angina
  • Uncontrolled cardiac arrhythmias causing symptoms
    or homodynamic compromise
  • Symptomatic severe aortic stenosis
  • Uncontrolled symptomatic heart failure
  • Acute pulmonary embolus or pulmonary infarction
  • Acute myocarditis or pericarditis
  • Active endocarditis
  • Acute aortic dissection
  • Acute noncardiac disorder that may affect
    exercise performance or be aggravated by exercise

  • Inability to obtain consent
  • Exercise standards for testing and training a
    statement for healthcare professionals from the
    American Heart Association. Circulation 2001
    1041694

15
Relative Contraindication to Exercise
  • Left main coronary stenosis or its equivalent
  • Moderate stenotic valvular heart disease
  • Electrolyte abnormalities
  • Severe hypertension (systolic 200 mmHg and/or
    diastolic 110 mmHg)
  • Tachyarrhythmias or bradyarrhythmias, including
    atrial fibrillation with uncontrolled ventricular
    rate
  • Hypertrophic cardiomyopathy and other forms of
    outflow tract obstruction
  • Mental or physical impairment leading to
    inability to cooperate
  • High-degree atrioventricular block
  • Exercise standards for testing and training a
    statement for healthcare professionals from the
    American Heart Association. Circulation 2001
    1041694

16
Cardiac Rehab Terminology
  • Content and duration Each exercise session
    includes three phases
  • Warm-up for 5 to 10 minutes. Warm-up exercises
    consist of stretching, flexibility movements
  • Conditioning or training phase, which consists of
    at least 20 minutes and preferably 30 to 45
    minutes of continuous aerobic activity.
  • Cool-down for 5 to 10 minutes. permits a gradual
    recovery from the conditioning phase.

17
Cardiac Rehab
  • Omission of cool-down can result in a transient
    decrease in venous return, reducing coronary
    blood flow when heart rate and myocardial oxygen
    consumption remain high.
  • Adverse consequences can include hypotension,
    angina, ischemic ST-T changes, and ventricular
    arrhythmias.

18
Maximum Heart Rate
  • Estimated as 220 minus the age in years (most
    common)
  • Maximum heart reached at peak exercise during a
    symptom-limited exercise tolerance test

19
Cardiac Rehab Exercise Intensity
  • Exercise intensity has been categorized using the
    percent HRmax as
  • Light (
  • Moderate (60 to 79 percent)
  • Heavy (80 percent)
  • The incremental benefit of very high intensity
    exercise (90 percent of HRmax) is small and is
    not recommended

20
Cardiac Rehab
  • Patients with stable angina may have an exercise
    prescription based upon 60 to 70 percent of the
    heart rate at which ischemic ST segment changes
    or anginal symptoms appear.

21
Cardiac Rehab Terminology
  • One MET is defined as 3.5 mL O2 uptake/kg per
    min, which is the resting oxygen uptake in a
    sitting position.

22
Extra Marital sex
23
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24
Overview
  • What is cardiac rehab
  • Components, Terminology Contraindication
  • Safety
  • Medicare Coverage
  • Evidence
  • STEMI UA/NSTEMI
  • Stable angina
  • Percutaneous coronary intervention
  • Coronary bypass surgery
  • Heart failure is not covered
  • Rehab Options at UIC and IL
  • Conclusions

25
Cardiac Rehab Safety
  • Supervision Important consideration when
    prescribing an exercise
  • Patients at moderate or high risk (Class C)
    should participate in a medically supervised
    program with ECG monitoring and personnel and
    equipment suitable for advanced cardiac life
    support.
  • This level of supervision should be continued for
    8 to 12 weeks until the safety of the prescribed
    exercise regimen has been established

26
Cardiac Rehab Safety
  • Exercise in Class B and C patients is associated
    with a small risk of adverse events.
  • The 2007 American Heart Association scientific
    statement on exercise the acute cardiovascular
    event rate estimated at one event in 60,000 to
    80,000 hours of supervised exercise (cardiac
    arrest, death or MI).

27
Cardiac Rehab Safety
  • Mortality rate in these setting is 1 per 784,000
    patient-hours.
  • Non fatal MI rate was 1 per 294,000 patients-hours

28
(No Transcript)
29
Overview
  • What is cardiac rehab
  • Components, Terminology Contraindication
  • Safety
  • Medicare Coverage
  • Evidence
  • STEMI UA/NSTEMI
  • Stable angina
  • Percutaneous coronary intervention
  • Coronary bypass surgery
  • Heart failure is not covered
  • Rehab Options at UIC and IL
  • Conclusions

30
Medicare Coverage
  • March 2006 Medicare expanded coverage of CR to
    include
  • Heart valve repair/replacement
  • Percutaneous transluminal coronary angioplasty or
    stenting
  • Heart or heart lung transplant
  • Also extended the time frame of performing the
    services to 36 sessions (generally 2-3 sessions
    per week for 12-18 weeks)

31
Medicare Coverage
  • COVERED
  • Documented diagnosis of acute myocardial
    infarction within the preceding 12 months
  • Coronary bypass surgery
  • Stable angina
  • Heart valve repair/replacement
  • Percutaneous coronary intervention
  • Heart or heart-lung transplant
  • NOT COVERED
  • Heart failure

32
Overview
  • What is cardiac rehab
  • Components, Terminology Contraindication
  • Safety
  • Medicare Coverage
  • Evidence
  • STEMI UA/NSTEMI
  • Stable angina
  • Percutaneous coronary intervention
  • Coronary bypass surgery
  • Heart failure is not covered
  • Rehab Options at UIC and IL
  • Conclusions

33
Evidence
  • STEMI Class IC
  • Cardiac rehabilitation/secondary prevention
    programs, when available, are recommended for
    patients with STEMI, particularly those with
    multiple modifiable risk factors and/or those
    moderate- to high-risk patients in whom
    supervised exercise training is warranted

New ACC/AHA Guidelines for the Management of
Patients with STEMI11/2/2004
34
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35
Evidence post STEMI
  • Meta-analysis (8440 patients) of total mortality
    for the exercise-only intervention demonstrated a
    reduction in all-cause mortality (random effects
    model OR 0.73 0.54, 0.98) compared with usual
    care.
  • Comprehensive cardiac rehabilitation reduced
    all-cause mortality but to a lesser degree (OR
    0.87 0.71, 1.05).
  • Neither of the interventions had any effect on
    the occurrence of nonfatal MI.
  • Jolliffe JA, Rees K, Taylor RS, Thompson D,
    Oldridge N, Ebrahim S. Exercise-based
    rehabilitation for coronary heart disease.
    Cochrane Database Syst Rev 2001 CD001800.

36
Evidence post STEMI
  • Results were of limited reliability because the
    quality of reporting in the studies was generally
    poor, and there were high losses to follow-up
  • Individual trials were small.
  • Trials were performed in the 1980s and earlier,
    before the contemporary advances in both the
    therapy and secondary prevention of MI

37
Updated 2007 UA/NSTEMI Guidelines
  • NSTEMI CLASS IB
  • Cardiac rehabilitation/secondary prevention
    programs, when available, are recommended for
    patients with UA/NSTEMI, particularly those with
    multiple modifiable risk factors and those
    moderate- to high-risk patients in whom
    supervised or monitored exercise training is
    warranted.
  • ACC/AHA 2007 Guidelines for the Management of
    Patients With Unstable Angina/NonST-Elevation
    Myocardial Infarction

38
Updated 2007 UA/NSTEMI Guidelines
  • 2005 meta-analysis of 11 trials of 2285 patients
    with coronary disease (most but not all post-MI)
    who were randomly assigned to exercise
    rehabilitation alone or control therapy.
  • Exercise was associated with a significant
    reduction in all-cause mortality (6.2 versus 9.0
    percent, summary risk ratio 0.72, 95 CI
    0.54-0.95).
  • There was an almost significant reduction in
    recurrent MI in the exercise group (summary risk
    ratio 0.76, 95 CI 0.57-1.01).
  • Meta-analysis secondary prevention programs for
    patients with coronary artery disease. AU Clark
    AM Hartling L Vandermeer B McAlister FA SO Ann
    Intern Med 2005 Nov 1143(9)659-72.

39
Updated 2007 UA/NSTEMI Guidelines
  • Retrospective study among 1,821 persons from 1982
    and 1998, with an incident MI hospitalized in
    Olmsted County
  • 58 men, 46 age 70 years)
  • 55 participated in cardiac rehabilitation.
    Participants had a lower risk of death and
    recurrent MI at three years (p 0.049, respectively).
  • The survival benefit associated with
    participation was stronger in more recent years
  • RR for 1998 vs. 1982 0.28, 95 CI 0.18 to 0.43
  • RR for 1990 vs. 1982 0.41, 95 CI 0.33 to 0.52).

  • Witt BJ, Jacobsen SJ, Weston SA, et al. Cardiac
    rehabilitation after myocardial infarction in the
    community. J Am Coll Cardiol 2004 44988 96.

40
  • Figure 2 Expected and observed survival by
    participation in cardiac rehabilitation. (A)
    non-participants (B) participants.

41
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42
Overview
  • What is cardiac rehab
  • Components, Terminology Contraindication
  • Safety
  • Medicare Coverage
  • Evidence
  • STEMI UA/NSTEMI
  • Stable angina Percutaneous coronary
    intervention
  • Coronary bypass surgery
  • Heart failure is not covered
  • Rehab Options at UIC and IL
  • Conclusions

43
Stable Angina
  • Class IB Comprehensive cardiac rehabilitation
    program
  • ACC/AHA 2002 Guideline Update for the Management
    of Patients With Chronic Stable Angina

44
Sable Angina
  • Nine randomized trials and four randomized trials
    have examined objective measures of ischemia
  • One study used ST-segment depression on
    ambulatory monitoring,
  • Three used exercise myocardial perfusion imaging
    .
  • Three of the four studies demonstrated a
    reduction in objective measures of ischemia in
    those patients randomized to the exercise group
    compared with the control group.

45
Stable Angina
46
Following PCI
  • Cardiac rehabilitation programs are recommended,
    particularly for those patients with multiple
    modifiable risk factors and/or those moderate- to
    high-risk patients in whom supervised exercise
    training is warranted.
  • ACC/AHA/SCAI 2005 Guideline Update for
    Percutaneous Coronary Intervention

47
Overview
  • What is cardiac rehab
  • Components, Terminology Contraindication
  • Safety
  • Medicare Coverage
  • Evidence
  • STEMI UA/NSTEMI
  • Stable angina Percutaneous coronary
    intervention
  • Coronary bypass surgery
  • Heart failure is not covered
  • Rehab Options at UIC and IL
  • Conclusions

48
Rehab CABG
  • Class IB
  • Cardiac rehabilitation should be offered to all
    eligible patients after CABG.
  • ACC/AHA Coronary Artery Bypass Graft Surgery
    (CABG) Guideline Update for Date 2004

49
Rehab CABG
  • Cardiac rehabilitation has been shown to reduce
    mortality
  • Cardiac rehabilitation beginning 4 to 8 weeks
    after coronary bypass and consisting of
    3-times-weekly educational and exercise sessions
    for 3 months is associated with a 35 increase in
    exercise tolerance (P equals 0.0001), a slight
    (2) but significant (P equals 0.05) increase in
    HDL-C, and a 6 reduction in body fat (P equals
    0.002)
  • Milani RV, Lavie CJ. The effects of body
    composition changes to observed improvements in
    cardiopulmonary parameters after exercise
    training with cardiac rehabilitation. Chest 1998
    113599-601

50
Overview
  • What is cardiac rehab
  • Components, Terminology Contraindication
  • Safety
  • Medicare Coverage
  • Evidence
  • STEMI UA/NSTEMI
  • Stable angina Percutaneous coronary
    intervention
  • Coronary bypass surgery
  • Heart failure is not covered
  • Rehab Options at UIC and IL
  • Conclusions

51
Rehab CHF
  • In the 1970s, exercise training of HF patients
    was discouraged due to concerns of worsening
    symptoms.
  • Early observations in the 1980s documented
    improvements in exercise function for patients
    with HF with a low rate of complications.

52
Rehab CHF
  • ACC/AHA guideline summary Management of patients
    with current or prior symptoms of heart failure
    (HF) and a reduced left ventricular ejection
    fraction (LVEF)
  • Class IC- Exercise training as an adjunctive
    approach to improve clinical status in ambulatory
    patients.  

53
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54
Rehab CHF
  • Meta-analysis of nine randomized controlled
    trials including 801 patients (395 of whom
    received exercise training compared to 406
    controls)
  • Exercise training reduces hospitalization and
    improves survival in patients with heart failure.

  • Follow up of 705 (729) days there were 88 (22)
    deaths in the exercise arm and 105 (26) in the
    control arm. (hazard ratio 0.65, 95 confidence
    interval, 0.46 to 0.92 log rank chi(2) 5.9 P
    0.015).
  • The secondary end point of death or admission to
    hospital was also reduced (0.72, 0.56 to 0.93
    log rank chi(2) 6.4 P 0.011).
  • BMJ 2004 Jan 24328(7433)189. Epub 2004 Jan 16.


55
Rehab CHF
  • The HF ACTION trial is testing the hypothesis
    that exercise training will reduce the combined
    end point of hospitalization and mortality in
    patients with NYHA class II-IV heart failure
  • This trial has completed enrollment and is
    positioned to completion in February of 2008.
  • Approximately 1500 patients will participate
    around the country and Canada for an average of
    four years.

56
Overview
  • What is cardiac rehab
  • Components, Terminology Contraindication
  • Safety
  • Medicare Coverage
  • Evidence
  • STEMI UA/NSTEMI
  • Stable angina Percutaneous coronary
    intervention
  • Coronary bypass surgery
  • Heart failure is not covered
  • Rehab Options at UIC and IL
  • Conclusions

57
Type of Rehab Programs
  • Exercise only Cardiac Rehab programs
  • Comprehensive Cardiac Rehab programs

58
  • UIC has an exercise only cardiac rehab program
    Outpatient PT
  • Perform 3 lead EKG monitoring
  • Develop training programs
  • Willing to work with primary physicians
  • Document results in power chart

59
AACVPR
  • Founded in 1985, the American Association of
    Cardiovascular and Pulmonary Rehabilitation
  • Certify comprehensive rehab programs
  • 42 Certified programs in IL
  • Advocate Christ Medical Center

60
Overview
  • What is cardiac rehab
  • Components, Terminology Contraindication
  • Safety
  • Medicare Coverage
  • Evidence
  • STEMI UA/NSTEMI
  • Stable angina Percutaneous coronary
    intervention
  • Coronary bypass surgery
  • Heart failure is not covered
  • Rehab Options at UIC and IL
  • Conclusions

61
Conclusion Cardiac Rehab
  • Vastly underutilized with less than 30 of
    patients participating in CR programs after a CV
    event.
  • Reasonable evidence of efficacy in various
    patient populations
  • Covered by Medicare in many populations
  • UIC does over exercise only programs
  • Overall this is something I will utilize more of
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