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Cardiac Rehabilitation Its Not Just About Exercise

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Bed rest as treatment for acute myocardial infarction. Physical effects of 7 days ... rehab has an exercise capacity of 7-8 MET's on a post event treadmill test ... – PowerPoint PPT presentation

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Title: Cardiac Rehabilitation Its Not Just About Exercise


1
Cardiac RehabilitationIts Not Just About
Exercise
  • Charles Dennis, MD
  • Virtua Health
  • The Cardiology Group, PC

2
Faculty Disclosure
  • Financial Disclosure
  • None
  • Unlabelled/Unapproved Uses Disclosure
  • None

3
History
  • Bed rest as treatment for acute myocardial
    infarction
  • Physical effects of 7 days of bed rest
  • 40 decrease in lean muscle mass
  • 70 decrease in peak aerobic capacity
  • Intravascular volume depletion
  • Increased vagal tone
  • Physical reconditioning was required to regain
    sufficient strength and endurance for ADL

4
Contemporary Clinical Management
  • Early diagnosis and rapid revascularization of
    myocardial infarction and unstable angina
  • Shortened hospitalizations for CABG patients
  • Early mobilization and discharge for most
    coronary patients
  • Minimal loss of physical conditioning

5
The Premise for Cardiac Rehab Has Changed
  • Physical reconditioning is less important
  • Exercise training is less relevant
  • Short term risk assessment is less important
  • Early post-event exercise testing is less
    relevant
  • Intermediate and long term risk assessment and
    management is paramount
  • Psychological recovery is paramount
  • Patient education is paramount

6
The Modern Paradigm in Coronary Disease
Management
  • Reduce Risk
  • Aggressive Lipid Management
  • Smoking Cessation and Abstinence
  • Hypertension Control
  • Diabetic Control
  • Ideal Body Weight
  • Restore Confidence
  • Physical Capability
  • Occupational Capacity
  • Sexual Activity
  • Increase Knowledge for Self-Care

7
Who Gets Rehab - And Who Doesnt
  • Does
  • Whites, 65-74 years old
  • Less than 3 miles away
  • Live in the Midwest (54)
  • Had CABG (33)
  • Older (over 65)
  • Overall 20 of eligible
  • Doesnt
  • Non-whites (33 less)
  • More than 6 miles away
  • Live in the South (6)
  • Had MI (14)
  • Younger (50 less likely)
  • Overall 80 of eligible
  • Basic Coverage
  • MI within 12 months, any history of CABG, valve
    surgery, stable angina or heart-lung transplant
  • 36 sessions over 12-18 weeks (with up to 72
    sessions)

8
Payment -The First Impediment
  • Medicare Reimbursement
  • 30 - 40 per patient per session
  • 1000 - 1400 for complete program
  • Private Insurance
  • 80 - 100 per patient per session
  • 2800 - 3600 for complete program
  • Medicare Supplements
  • Intermediate payment to bring total program
    reimbursement closer to private insurance level

9
Program Organization
  • Still structured around exercise training
  • Stress test or not?
  • Intake evaluation
  • Exercise prescription
  • Risk factor assessment
  • Risk factor treatment plan
  • Exercise Program (with add-ons)
  • Structured exercise training
  • Psychological support
  • Patient education
  • Risk factor management

10
The 80 Solution
  • 80 of your eligible patients are not going to
    participate in structured cardiac rehabilitation
  • Those patients still need many of the services
    offered by cardiac rehabilitation
  • Other than monitored exercise, you can provide
    the services they need

11
Cardiac Rehab R Us
  • Home Exercise Training
  • Risk Factor Management
  • Lipid Management
  • Blood Pressure Management
  • Diabetic Control
  • Smoking Cessation
  • Psychological Support and Self Efficacy
  • Patient Education

12
Monitored Versus Unmonitored Exercise Training
  • Safety
  • With appropriate risk stratification (ie.,
    symptom-limited stress test), equally safe
  • Efficacy
  • Monitored programs have slightly higher exercise
    capacity at 6 weeks
  • No difference between monitored and unmonitored
    training at 12 weeks

13
Exercise Testing Before Rehab?
  • None
  • Base program on age predicted heart rate
  • Sub-maximal
  • Risk stratification
  • Correlate heart rate to exercise capacity
  • Usually underestimates peak capacity
  • Symptom-limited
  • Risk stratification
  • Measures peak capacity
  • Provides more accurate exercise prescription

14
Exercise Prescription
  • No Stress Test
  • Based on 65-85 predicted maximal heart rate
    (PMHR)
  • PMHR 220 - age
  • Very wide confidence intervals around PMHR
  • Stress Test
  • Sub-maximal - Based upon estimated peak exercise
    capacity
  • Symptom-limited - Based upon actual peak exercise
    capacity

15
Exercise Training
  • Frequency
  • Four times weekly
  • Intensity
  • 85 of maximal heart rate
  • Time
  • 30-45 minutes of continuous aerobic exercise
  • Safety
  • Start low, go slow

16
Tips for Unmonitored Training
  • Stress test is mandatory for risk stratification
  • Symptom-limited stress testing is preferred
  • Low risk patients with ischemia exercise at 20
    bpm below ischemic threshold
  • Start low, go slow
  • The biggest risk is orthopedic injury - warm-up
    and cool-down
  • You dont need a 75 jogging suit, 125 pair of
    Nikes or a heart rate monitor
  • Avoid very hot and very cold weather

17
The Borg ScaleRate of Perceived Exertion (RPE)
6 7 Very, very light 8 9 Very
light 10 11 Fairly light 12 13 Somewhat
hard 14 15 Hard 16 17 Very hard 18 19 Very, very
hard 20
18
Manage the NumbersBlood Pressure, Blood
Cholesterol, Blood Sugar
  • Blood Pressure
  • For most patients, BP lt 130/80 mmHg
  • Lipids - Follow the NCEP Guidelines
  • For most patients, LDL goal of lt 100 mg/dl
  • Blood Sugar
  • HgbA1c lt 6.5 (or lt 7)

19
Smoking CessationThe 20 Minute Program
  • Determine if the patient is ready to quit
  • Set a quit date
  • Determine degree of nicotine dependence
  • How soon after you wake up in the morning do you
    have to have a cigarette?
  • Do you have trouble abstaining even where smoking
    is forbidden?
  • Do you smoke more in the first few hours after
    waking up than the rest of the day?

20
Smoking CessationThe 20 Minute Program
  • Prepare to stop smoking
  • Get rid of all cigarettes
  • Throw away all ashtrays
  • Air out the house, detail the car
  • Tell your family and friends
  • Plan on how you will spend the 100 per month (_at_
    3.81 per pack)

21
Smoking Cessation
  • Identify linked behaviors and make a plan
  • After meals
  • Driving
  • Talking on the telephone
  • Coffee
  • Stress
  • Alcohol
  • Quit with others
  • Consider pharmacologic help

22
Chantix (Verenicline)
  • Blocks nicotine receptors in the brain
  • Side-effects
  • Nausea (30), other GI symptoms, sleep
    disturbance
  • Neuropsychiatric issues
  • Contraindications
  • Renal failure, pregnancy
  • No Clinically Important Drug Interactions
  • Effectiveness
  • 50 abstinent at 3 months, 25abstinent at 6
    months
  • Dosage
  • 0.5 mg daily for 3 days, 0.5 mg BID for 5 days, 1
    mg BID through end of treatment (12 weeks)

23
Zyban/Wellbutrin (Bupropion)
  • Mechanism of action unknown
  • Side-effects
  • Sleep disturbance (35), dry mouth (10), GI
    symptoms
  • Contraindications
  • Taking bupropion, seizures, eating disorder,
    alcoholism, neuropsychiatric issues, pregnancy
  • Interactions
  • MAO inhibitors, drugs metabolized by C450
    (antidepressants, beta-blockers, antiarrhythmics,
    and antipsychotics)
  • Effectiveness
  • 50 abstinent at 6 months, 25abstinent at 12
    months
  • Dosage
  • 150 mg daily for 3 days, then 150 mg BID,
    starting two weeks before smoking cessation

24
Nicotine Replacement Therapy (NRT)
  • Patch, gum, inhaler, nasal spray
  • Mechanism is tapering dose of nicotine
  • Contraindications
  • Relative - Pregnancy, arrhythmias. frequent
    angina
  • No known drug interactions
  • Effectiveness
  • 1.5 - 2 times as effective as counseling alone
  • 35 six-month abstinence rate
  • Dosage
  • Varies by formulation

25
Smoking Cessation
  • Relapse
  • 90 will relapse with at least one cigarette
    within six months
  • Have a plan
  • Not a failure
  • Not an open door to resume smoking
  • Make me a promise

26
Self Efficacy
  • Definition - An individuals belief about his/her
    capability to produce effects
  • Low self efficacy predicts failure and an
    unwilling ness to try again
  • High self efficacy predicts a willingness to try
    and a resolve to work through failure

27
Self Efficacy
  • Increasing Self Efficacy
  • Mastery experiences - early success, persistent
    effort
  • Vicarious experiences - seeing people similar to
    oneself succeed by sustained effort
  • Social persuasion - being persuaded verbally that
    one has the capability to succeed
  • Four Psychological Processes
  • Cognitive - organize thought and rehearse
    experience
  • Motivational - causal attribution, outcome
    expectancies, cognized goals
  • Affective - coping capabilities
  • Selection - activities and challenges patients
    opt to initiate

Bandura, A, Encyclopedia of human behavior, 1994
28
Restoring Confidence Using Self Efficacy
  • Exercise Training
  • Mastery experience - Symptom-limited stress test
  • Social persuasion - Tell the patient, based upon
    the stress test that they can safely and
    effectively exercise
  • Vicarious experience - Monitored exercise
    programs
  • Cognitive - Rehearse success
  • Motivational -Relate exercise to improved health
    and capacity, expect fatigue and dyspnea, form
    progressive goals
  • Coping - Minimize fear based upon stress test
  • Selection - start low, go slow

29
Occupational Work
  • Average patient eligible for cardiac rehab has an
    exercise capacity of 7-8 METs on a post event
    treadmill test
  • Average peak effort for occupational work
    (excluding manual labor) is 3-4 METs
  • Average person can easily sustain work at 50 of
    peak capacity for 6-8 hours
  • Delayed return to work is more often the
    physicians and spouses fault than the physical
    capacity of the patient

30
Self Knowledge for Self Care
  • Post Event patients need to know
  • How to recognize and treat angina
  • When to access 911
  • How to recognize and respond to other cardiac
    symptoms, particularly related to heart failure
    and arrhythmias
  • What their medications are, what they do, and how
    to take them
  • What their medical condition is and how they can
    improve their health

31
Sexual Activity
  • Requires 2-3 METs capacity pre-orgasmic and 3-4
    METs orgasmic activity
  • Average peak heart rate with a familiar partner
    is 120 bpm
  • Less than 1 of MIs occur during sexual activity
  • Relative risk is increased by recent MI or ACS
  • Negative stress test associated with
    significantly lowered risk

32
Cardiac Rehabilitation ProgramsA Pitch
  • Cardiac Rehab R Us does not really work
  • Organized cardiac rehabilitation programs
  • Consist of trained and highly skilled individuals
    who love what they do
  • Improve patient self-efficacy for physical
    activity, occupational work, sexual activity and
    medication compliance
  • Improve patients knowledge about their condition
    and teach them appropriate symptom recognition
    and response
  • Cut recovery time by 50
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