Transcript Cardiac Rehabilitation Jan-09-07

Cardiac Rehabilitation
st
November 1 , 2007
Jeffrey Marogil, MD
UIC Cardiology
Introduction
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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.
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
Introduction
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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.
Overview
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What is cardiac rehab
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Medicare Coverage
Evidence
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Components, Terminology & Contraindication
Safety
STEMI UA/NSTEMI
Stable angina & Percutaneous coronary intervention
Coronary bypass surgery
Heart failure
Rehab Options at UIC and in IL
Conclusions
What is Cardiac Rehab?
Definition:
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Cardiac rehabilitations services are comprehensive,
long-term programs involving
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medical evaluation,
prescribed exercise,
cardiac risk factor modification,
educations and counseling.
These programs are designed to limit the
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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
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2007 American Association of Cardiovascular
and Pulmonary Rehabilitation/AHA/ACC
Guidelines
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Performance Measures on Cardiac Rehabilitation for Referral to and
Delivery of Cardiac Rehabilitation/Secondary Prevention Services:
J Am Coll Cardiol 2007;50:1400-33
Cardiac Rehab Terminology
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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
Cardiac Rehab Terminology
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Risk Stratification for Exercise
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Class A
Class B
Class C
Class D
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Guidelines published by the American Heart Association use four
categories of risk according to clinical characteristics
Cardiac Rehab Terminology
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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.
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Guidelines published by the American Heart Association use four
categories of risk according to clinical characteristics
Cardiac Rehab Terminology
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Class C: moderate or high risk of cardiac
complications (multiple myocardial infarctions or
cardiac arrest, NYHA class III or IV, Exercise capacity
of < 6 METs, or significant ischemia on the exercise
test.
Class D: unstable disease for whom exercise is
contraindicated.
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Guidelines published by the American Heart Association use four
categories of risk according to clinical characteristics
Absolute Contraindication to
Exercise
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Absolute Acute myocardial infarction (within two days)
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Unstable angina
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Uncontrolled cardiac arrhythmias causing symptoms or homodynamic compromise
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Symptomatic severe aortic stenosis
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Uncontrolled symptomatic heart failure
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Acute pulmonary embolus or pulmonary infarction
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Acute myocarditis or pericarditis
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Active endocarditis
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Acute aortic dissection
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Acute noncardiac disorder that may affect exercise performance or be aggravated by
exercise
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Inability to obtain consent
Exercise standards for testing and training: a statement for healthcare professionals from
the American Heart Association. Circulation 2001; 104:1694
Relative Contraindication to Exercise
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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; 104:1694;
Cardiac Rehab Terminology
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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.
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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.
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Maximum Heart Rate
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Estimated as 220 minus the age in years (most
common)
Maximum heart reached at peak exercise during
a symptom-limited exercise tolerance test
Cardiac Rehab Exercise Intensity
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Exercise intensity has been categorized using the
percent HRmax as:
Light (<60 percent)
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
Cardiac Rehab
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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.
Cardiac Rehab Terminology
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One MET is defined as 3.5 mL O2 uptake/kg
per min, which is the resting oxygen uptake in a
sitting position.
Extra Marital sex
Overview
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What is cardiac rehab
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Medicare Coverage
Evidence
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Components, Terminology & Contraindication
Safety
STEMI UA/NSTEMI
Stable angina
Percutaneous coronary intervention
Coronary bypass surgery
Heart failure is not covered
Rehab Options at UIC and IL
Conclusions
Cardiac Rehab Safety
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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
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Cardiac Rehab Safety
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Exercise in Class B and C patients is associated
with a small risk of adverse events.
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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).
Cardiac Rehab Safety
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Mortality rate in these setting is 1 per 784,000
patient-hours.
Non fatal MI rate was 1 per 294,000 patientshours
Overview
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What is cardiac rehab
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Medicare Coverage
Evidence
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Components, Terminology & Contraindication
Safety
STEMI UA/NSTEMI
Stable angina
Percutaneous coronary intervention
Coronary bypass surgery
Heart failure is not covered
Rehab Options at UIC and IL
Conclusions
Medicare Coverage
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March 2006 Medicare expanded coverage of CR
to include
Heart valve repair/replacement
 Percutaneous transluminal coronary angioplasty or
stenting
 Heart or heart lung transplant
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Also extended the time frame of performing the
services to 36 sessions (generally 2-3 sessions
per week for 12-18 weeks)
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
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Heart failure
Overview
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What is cardiac rehab
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Medicare Coverage
Evidence
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Components, Terminology & Contraindication
Safety
STEMI UA/NSTEMI
Stable angina
Percutaneous coronary intervention
Coronary bypass surgery
Heart failure is not covered
Rehab Options at UIC and IL
Conclusions
Evidence
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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 STEMI
11/2/2004
Evidence post STEMI
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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. Exercisebased rehabilitation for coronary heart disease. Cochrane Database Syst Rev
2001 CD001800.
Evidence post STEMI
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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
Updated 2007 UA/NSTEMI
Guidelines
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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.
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ACC/AHA 2007 Guidelines for the Management of Patients
With Unstable Angina/Non–ST-Elevation Myocardial
Infarction
Updated 2007 UA/NSTEMI
Guidelines
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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 1;143(9):659-72.
Updated 2007 UA/NSTEMI
Guidelines
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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 < 0.001 and p = 0.049, respectively).
The survival benefit associated with participation was stronger in more recent
years
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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; 44:988 –96.
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Figure 2 Expected and observed
survival by participation in cardiac
rehabilitation. (A) non-participants;
(B) participants.
Overview
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What is cardiac rehab
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Medicare Coverage
Evidence
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Components, Terminology & Contraindication
Safety
STEMI UA/NSTEMI
Stable angina & Percutaneous coronary intervention
Coronary bypass surgery
Heart failure is not covered
Rehab Options at UIC and IL
Conclusions
Stable Angina
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Class IB: Comprehensive cardiac
rehabilitation program
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ACC/AHA 2002 Guideline Update for the
Management of Patients With Chronic
Stable Angina
Sable Angina
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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.
Stable Angina
Following PCI
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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.
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ACC/AHA/SCAI 2005 Guideline Update for
Percutaneous Coronary Intervention
Overview
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What is cardiac rehab
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Medicare Coverage
Evidence
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Components, Terminology & Contraindication
Safety
STEMI UA/NSTEMI
Stable angina & Percutaneous coronary intervention
Coronary bypass surgery
Heart failure is not covered
Rehab Options at UIC and IL
Conclusions
Rehab & CABG
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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
Rehab & CABG
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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; 113:599-601
Overview
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What is cardiac rehab
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Medicare Coverage
Evidence
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Components, Terminology & Contraindication
Safety
STEMI UA/NSTEMI
Stable angina & Percutaneous coronary intervention
Coronary bypass surgery
Heart failure is not covered
Rehab Options at UIC and IL
Conclusions
Rehab & CHF
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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.
Rehab & CHF
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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.
Rehab & CHF
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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 24;328(7433):189. Epub 2004 Jan 16.
Rehab & CHF
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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.
Overview
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What is cardiac rehab
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Medicare Coverage
Evidence
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Components, Terminology & Contraindication
Safety
STEMI UA/NSTEMI
Stable angina & Percutaneous coronary intervention
Coronary bypass surgery
Heart failure is not covered
Rehab Options at UIC and IL
Conclusions
Type of Rehab Programs
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Exercise only Cardiac Rehab programs
Comprehensive Cardiac Rehab programs
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
AACVPR
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Founded in 1985, the American Association of
Cardiovascular and Pulmonary Rehabilitation
Certify comprehensive rehab programs
42 Certified programs in IL
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Advocate Christ Medical Center
Overview
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What is cardiac rehab
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Medicare Coverage
Evidence
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Components, Terminology & Contraindication
Safety
STEMI UA/NSTEMI
Stable angina & Percutaneous coronary intervention
Coronary bypass surgery
Heart failure is not covered
Rehab Options at UIC and IL
Conclusions
Conclusion: Cardiac Rehab
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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