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Cardiac Rehabilitation

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Benefits of Cardiac Rehabilitation: Impact on Mortality, Hospitalizations and Risk Factors Reggie Higashi, MSS Exercise Physiologist Core Program Components Baseline ... – PowerPoint PPT presentation

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Title: Cardiac Rehabilitation


1
Benefits of Cardiac Rehabilitation Impact on
Mortality, Hospitalizations and Risk Factors
Reggie Higashi, MSS Exercise Physiologist
2
Core Program Components
  • Baseline clinical evaluation patient assessment
  • Risk factor management and goal setting
  • Psychosocial management
  • Physical activity counseling
  • Exercise training

Balady, G. et al. Core components of cardiac
rehabilitation/secondary prevention programs A
statement for healthcare professionals from the
American Heart Association and the American
Association of Cardiovascular and Pulmonary
Rehabilitation. Circulation, 2000 1021069-1073.
3
Approved Diagnoses(Medicare)
  • Myocardial infarction
  • Within 1 year
  • Stable angina
  • Coronary artery bypass grafting
  • Within 1 year

Ref Section 3525 of the "Medicare Procedure
Manual" Cardiac Rehabilitation Programs
4
Approved Diagnoses(Non-Medicare)
  • Myocardial infarction
  • Stable angina
  • CABG
  • PTCA/Stent placement
  • Heart failure
  • PAD
  • Recent ICD implant
  • Arrhythmias
  • Valve replacement/repair
  • Heart transplant

5
Cardiac Rehab Programs
  • Monitored outpatient program
  • 3 days/week for up to 12 weeks
  • Covered by Medicare (MI, angina, CABG)
  • Modified monitored outpatient program
  • 3 days/week for up to 4 months
  • Not covered by insurance
  • Extended outpatient program (after monitored or
    modified program)
  • 3 days/week for up to 4 months
  • Not covered by insurance
  • Maintenance program (after extended program)
  • 2 days/week

6
Monitored Outpatient Program
  • One hour cardiac monitored exercise sessions
  • 3 days/week, MWF for up to 12 weeks
  • Various class times in morning and afternoon
  • Guided warm-up, three 10-minute aerobic stations,
    guided cool-down
  • Blood pressure monitored pre, during and
    post-exercise
  • Monthly and final reports sent to referring M.D.
  • Medicare/Insurance covered diagnoses (MI, CABG,
    Stable Angina)

7
Modified Monitored Outpatient Program
  • Telemetry monitored for first 2 weeks, then
    patient is placed on personal heart rate monitor
    for the remainder of program
  • 3 days/week, MWF for up to 4 months enrollment
    limit
  • Various class times in morning and afternoon
  • Guided warm-up, three 10-minute aerobic stations,
    guided cool-down
  • Blood pressure monitored pre, during and
    post-exercise
  • Monthly and final reports sent to referring M.D.
  • Costs 325 for initial month (includes costs of
    personal heart rate monitor) then 40 per month
    for the remaining 3 months.
  • (Self-Pay Not covered by insurance)

8
Extended Outpatient Program
  • One hour non cardiac-monitored exercise sessions
  • 3 days/week, MWF for up to 4 months enrollment
    limit
  • Various class times in morning and afternoon
  • Guided warm-up, three 10-minute aerobic stations,
    guided cool-down
  • Blood pressure monitored pre, during and
    post-exercise
  • Cardiac monitoring 1x/month
  • Monthly reports with telemetry cardiac monitoring
    sent to referring M.D.
  • Self Pay 40/month (Not covered by insurance)
  • Must complete monitored or modified monitored
    program to enroll in this program.

9
Maintenance Program
  • One hour non cardiac-monitored exercise sessions
  • 2 days/week, Tu Th, 800 a.m. - 900 a.m.
  • Guided warm-up, four 10-minute aerobic stations,
    guided cool-down
  • Blood pressure monitored 1x/month as as needed
  • Heart Rate checks pre, during and post-exercise
    by patient
  • Copy of monthly exercise logs given to patient.
  • Self Pay 30/month (not covered by insurance)
  • Must complete extended out-patient program to
    enroll in this program.

10
Effect of Exercise-Based Cardiac Rehab on Cardiac
Events in Patients with CAD (MI, angina, CABG,
PCI)
Exercise Only Comprehensive Program
Non-fatal MI - 4 - 12
Cardiac Mortality - 31 - 26
Jolliffe et al. Meta-Analysis, 2001. 51
randomized, controlled trials (n 4,000) 2 6
months of supervised rehab, then unsupervised
Mean follow-up of 2 4 years
11
Utilization of Cardiac Rehab by Patients After MI
  • Ades et al , 1992 reviewed utilization of cardiac
    rehab by patients within 1 hour of rehab center
  • Age Dependence of Utilization
  • lt 62 yrs 46 utilization
  • gt 62 yrs 21 utilization
  • Most powerful predictor of utilization was
    recommendation of primary care physician to
    participate

12
Potential Explanation for Reduced Mortality
Without Impact on Non-fatal MI
  • Ischemic preconditioning
  • Animals having repeated episodes of temporary
    coronary occlusion have smaller MI when occlusion
    is permanent
  • Electrical stability and reduced ventricular
    fibrillation

13
Exercise Training in Patients with Angina
  • Improved myocardial oxygen supply at a given
    level demand
  • Increase in rate pressure product at onset of
    angina (reduction in exercise heart rate)
  • Decrease in nuclear scan perfusion defects (as
    early as 8 weeks)
  • Less ST segment depression
  • Proposed mechanisms
  • Improved endothelial function (angio studies)
  • Increased coronary collaterals
  • Regression and reduction in progression of CAD (1
    yr studies)

14
Exercise Training After Coronary
Revascularization (CABG/PCI)
  • No large studies
  • ETICA Trial (Exercise Training Intervention after
    Coronary Angioplasty Trial, 2001
  • 118 patients underwent 6 months of exercise
    training or control. Follow-up of 33 7 months
  • Improved exercise capacity (26 increase in v02)
  • Fewer cardiac events (12 vs 32)
  • Fewer hospital admissions (19 vs. 46)
  • No impact on restenosis

15
Exercise Training for Patients With CHF
  • gt 20 studies document improvements in
  • Exercise capacity
  • 20 improvement in v02 after 4 weeks
  • 18 34 increase in time on treadmill after 12
    wks
  • Quality of life
  • Hospitalization and mortality
  • Belardinelli et al (Circ, 1999) Small trial that
    demonstrated improved exercise capacity,
    decreased hospitalization and improved 1 yr
    survival
  • HF-ACTION NIH Study
  • Compares usual care with addition of formal
    exercise training
  • Endpoints of mortality and hospitalization

16
Exercise Training for Patients with PAD and
Claudication
  • Improvements in distance to onset of pain
    (increased by 179 225 m) and distance to
    maximal tolerated pain (increased by 122 397
    m)
  • Improvements with exercise exceed those with meds
    (I.e., Trental, Pletal)
  • Most significant improvements when
  • Walking as training
  • Walking to maximal pain
  • Training period for 6 months

Meta-Analysis of 21 exercise programs Gardner and
Poehlman, JAMA, 1995
17
Proposed Mechanisms for Improved Outcomes with
Exercise Therapy
  • Favorable impact on risk factors
  • Lipids
  • Blood pressure
  • Body weight
  • Insulin sensitivity
  • Enhanced parasympathetic tone
  • Improved endothelial function
  • Lower catecholamine levels with exercise may
    reduce platelet aggregation

18
Impact on Risk FactorsCholesterol Reduction
  • LDL decrease of 5 (8 12 decrease with
    combined exercise and diet therapy)
  • HDL increase of 4.6
  • Triglyceride decrease of 3.7

Meta-Analysis (2001) of 52 trials, n 4700, gt
12 weeks of training
19
Impact on Risk FactorsDiabetes Mellitus
  • Decrease in hemoglobin A1C by 0.5 to 1.0
  • Mechanisms proposed Increased insulin
    sensitivity and decreased hepatic glucose
    production
  • Data from 9 trials, 337 patients with diabetes
    mellitus, type 2
  • Role of physical activity and weight loss in
    preventing type 2 diabetes mellitus in patients
    at risk
  • Diabetes Prevention Program (NEJM, 2002)
  • 58 reduction in onset of diabetes over 2.8 years
    (vs 31 reduction with metformin 850 mg BID)

Average weight loss of 4.4 kg Increase activity
by 8 met hr/week 6 mile walk per week
20
Impact on Risk FactorsBlood Pressure Reduction
Overall Normotensive Hypertensive
Systolic - 3.4 2.6 - 7.4
Diastolic - 2.4 - 1.8 - 5.8
44 Trials, n 2,674
21
Impact on Risk FactorsSmoking
  • Useful as adjunct to behavioral programs
  • Results of 12 week exercise program in 281 women
  • 19 abstain after program (vs 10)
  • 12 abstain at 1 year (vs 5)

22
Impact on Risk FactorsWeight Reduction
Exercise 2 3 kg
Diet 5 5 ½ kg
Diet and Exercise 8 ½ kg
23
Favorable Effects of Exercise Training
  • Endothelial Function
  • Fibrinolytic System
  • Platelet Function

24
Exercise Therapy and Platelet Function
  • An increase in platelet aggregation can occur
    after exercise in sedentary individuals (possibly
    related to increased catecholamines)
  • After 12 week exercise training program, platelet
    aggregation decreased by 52 in a study of middle
    age, hypertensive male subjects

25
Exercise Therapy and Fibrinolytic System
Plasma Fibrinogen - 13
Tissue Plasminogen Activator 39
Plasminogen activator inhibitor - 1 - 58
26
SummaryBenefits of Exercise-Based Cardiac
Programs
  • 30 decrease in mortality in patients with CAD
    (Decrease in mortality also reported in CHF)
  • Decrease in hospitalizations after coronary
    revascularization and with CHF
  • Improved exercise tolerance in patients with
    claudication and PAD
  • Favorable impact on risk factors

27
Exercise Recommendation(AHA/CDC/ACSM)
  • 30 minutes or more of moderate intensity of
    physical activity on most (preferably all) days
    of the week
  • Moderate intensity
  • Absolute intensity 4 6 mets
  • Relative intensity 40 60 of v02 max
  • 4 mets may be vigorous for an 80 yr old and
  • light for a 20 yr old

28
Thank you all for attending todays lecture. Any
Questions???
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