Transcript Mayo Clinic Cardiology Update at South Beach: A Focus on

Beneficios de la
Rehabilitacion
Cardiovascular
Marzo 15, 2016
Fundacion Cardiovascular Dr. Jorge Kaplan Meyer
Carmen Militza Terzic, MD, PhD
Professor and Chair Department of Physical Medicine and Rehabilitation,
Co-Director Cardiovascular Rehabilitation
Mayo Clinic Rochester, Minnesota, U.S.A.
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2003 Heart Disease Statistics
• Worldwide, 17 million people
die of CVD/year accounting
for 1/3 of global death
• In the USA, CVD claimed 40%
of all deaths far exceeding
all cancer, diabetes, respiratory
and infectious diseases combined
Rehabilitation and prevention are essential
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Cardiac Rehabilitation
Multidisciplinary approach focusing on
therapeutic education, individualized exercise
training, risk factors management, and
optimization of functional status and mental
health through regular patient evaluation,
monitoring and support of compliance and
adherence
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Cardiac Rehabilitation
Participants in a cardiac rehabilitation include
patients: after an acute coronary syndrome,
cardiac surgery (CABG, valve
replacement/repair, transplant, ventricular
reductions surgery and congenital heart repair,
LVAD), patients with compensate congestive
heart failure.
Gold standard of cardiac care
after acute events
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How Does CRP help to control CVD?
Healthy lifestyle interventions are a medical necessity that
should be prescribed to all individuals.
For patients with CVD, the most wellestablished model for healthy lifestyle
interventions in the current healthcare model is
Cardiac Rehabilitation
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Cardiac Rehabilitation
Benefits
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Cardiac Rehabilitation
• Improves Symptoms of Exertion
• Dyspnea
• Fatigue
• Claudication
• Improves Autonomic tone: increased vagal activity
attenuated sympathetic hyperactivity, increase heart
rate variability and recovery, reduce resting pulse.
• Improves Cardiorespiratory fitness
• 10% to 40% increase in aerobic capacity
(VO2 peak)
• Estimated metabolic equivalents +35%
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Rate of Death Due to CHD by Fitness Level:
The Aerobic Center Study
Men
Women
No. of participants
Age (y), mean
Follow-up (y)
10,224
41.5
8
3120
40.8
8
Cardiopulmonary fitness level
Low
Moderate
High
24.6
7.8
3.1
7.4
2.9
0.8
Rate of death due to CHD per 10,000 person-years.
Increased levels of physical activity, exercise training, and overall
cardiorespiratory fitness have provided protection in the primary and
secondary prevention of CHD
Blair et al., JAMA 1989
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Cardiac Rehabilitation Program:
Lipids and Inflammation
• Improvement in the blood lipid profile:
• Total cholesterol (decrease 7 to 13 mg/d)
• LDL (3 to 11 mg/dL)
• Triglycerides (-15%)
• HDL by 6% (13-16% increase in patients
with low HDL-C levels)
Greater improvements in patients with very
abnormal values
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Median changes in high-sensitive C-reactive
protein in control patients with coronary heart
disease (CHD) and cardiac rehabilitation patients.
Carl J. Lavie et al. Circulation Research. 2015;117:207-219
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Cardiac Rehabilitation
Improvements in CVD Risk Factors
Improve Insulin Resistance
Lower blood pressure in hypertensive and normal
individuals by 6 to 9 mm Hg (systolic and diastolic)
Improves metabolic syndrome by 37 %
Reduction % fat: -5
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Cardiac Rehabilitation Program:
Weight loss
• Promotion of weight loss and weight
maintenance
377 patients Mayo Clinic
Weight loss (intentional with diet/exercise)
associated with reduction mortality and
major CVD events
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Cardiac Rehabilitation Program:
Psychological Risks Factors
May trigger
acute CV
events
High
prevalent
Psychosocial
stress
CVD Risk
factor
Barrier for
medical
interventions
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Depression is associated with an increased risk for a
combination of death or rehospitalization for heart
failure, myocardial infarction, or stroke
Kaplan-Meier estimated survival in 56,064 patients with or without
depression diagnosis before primary isolated CABG from 1997 to 2008 in
Sweden.
Malin Stenman, Martin J. Holzmann, Ulrik Sartipy
The American Journal of Cardiology, Volume 114, Issue 5, 2014
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Effect of cardiac rehabilitation programs on prevalence of
adverse psychological stress parameters (depression, anxiety,
and hostility) in younger and older patients with CHD.
Carl J. Lavie et al. Circulation Research. 2015;117:207-219
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• Effect of CR on mortality rates in 139 patients
with baseline depression
Reduction of mortality by 70% in patients with
depression compared with control groups (patients
with CVD and no participation in CR)
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Cardiac Rehabilitation
Sleep Apnea Screening
Independent risk factor for ischemic heart disease and
other vascular diseases as well as all cause mortality
Hung, Lancet, 1990;
Somers, Mayo Clinic Proceedings, 2004
Lopez-Jimenez, Chest, 2008
Dong, Atherosclerosis, 2013
Marshall, J Clin Sleep Med., 2014
Ghazal Atheroscler. 2015
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Cardiovascular Consequences of OSA
Fatal events
Non-fatal myocardial infarction, PTCA, stroke
Marin, S.J. et al., Lancet, 2005
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Random-effects meta-analysis of the relationship between
obstructive sleep apnea (OSA) and risk of coronary heart disease
(CHD). CI = confidence interval; F = female; M = male; RR =
relative risk.
All combined, OSA was associated with increased risk of developing
CHD (RR = 1.37, 0.95–1.98)
Jia-Yi Dong, Yong-Hong Zhang, Li-Qiang Qin
Atherosclerosis, Volume 229, Issue 2, 2013, 489–495
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Cardiac Rehabilitation
Others benefits
Smoking Cessation
Assess/intervene/support/follow
The strongest predictor of SC at 6 months after PCI was
participation in cardiac rehabilitation
odds ratio [OR] 3.17, 95% confidence interval [CI] 2.05 to 4.91
p <0.001)
Sochor et al., Am J Cardiol. 2015
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Medication Adherence and CRP
Year 1
Year 3
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Statin
Aspirin
ACEI or ARB
Beta Blocker
Mayo Case Mayo Clinic Cardiac Rehabilitation Program Outcomes. Squires et al, JCRP 2008;28:180-186
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Meeting Risk Factor Goals
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Cardiac Rehabilitation:
• CVD Hospitalizations
• CVD Mortality
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Cardiac Rehabilitation:
Impact on Re-admission Rates after MI
• Olmsted County, MN
• 2991 patients
• 1st time MI, 1987-2010
• 52% in CR
• CR = ↓ hospitalization
• All-cause: ↓ 25%
• CV: ↓ 20%
• Non-CV: ↓ 28%
Similar benefit seen after PCI and CABG
Am J Med 2014
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Mortality After Myocardial Infarction for Cardiac
Rehabilitation Participants and Non-Participants
Population-based surveillance study of residents discharged from the hospital
following their first-ever myocardial infarction in Olmsted County, Minnesota from
January 1, 1987 to September 30, 2010
Am J Med. 2014
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Cardiac Rehabilitation
and Mortality Impact in PCI
• Mayo Clinic CR-PCI Study
• Post PCI patients, 1994-2008
• Cardiac rehabilitation vs no CR
• Adjusted Propensity Score Analysis
techniques
• All-cause mortality 45% lower for CR
participants
• Mortality benefit began in year one and
persisted
• Goel et al., 2011 Circulation
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Cardiac Rehabilitation
and Mortality Impact in CABG
• Mayo Clinic Study
• Post CABG 846 patients, 10 years follow up
• Cardiac rehabilitation vs no CR
• All-cause mortality was reduced by 46% in
CR participants
Pack et al., 2015 Am. J. Cardiology
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Cardiac Rehabilitation and HF
• 1 MET increase is associated with 20%reduction
of HF risk
• 15 to 17% improvement of peak V02 is associated
with reductions in hospitalization (28%) and
mortality (35%)
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Cardiac Rehabilitation and HF
• HF-ACTION Trial
• 30% reduction combined end point of
hospitalization and all cause mortality among
sub groups that achieved exercise prescription
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Cardiac Rehabilitation
Financial issues: cardiac rehabilitation
improves prognosis after CVD events in a
highly cost effective manner by reducing
recurrent hospitalization, health care
expenditures while prolonging life
IMPROVEMENTS IN OVERALL QUALITY OF
LIFE
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Other benefits?
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Enhancing Treatment for Cardiovascular Disease: Exercise and
Circulating Angiogenic Cells.
Witkowski, et al Exercise & Sport Sciences Reviews. 2011.
2
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Endurance training increases the number of endothelial
progenitor cells in patients with cardiovascular risk and
coronary artery disease
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A single exercise bout improves circulating
angiogenic cell migration in severe and mild chronic
heart failure, restoring it to levels similar to healthy
subjects.
Van Craenenbroeck et al, European Heart Journal , 2010
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How Does CRP help to control CVD?
- Education about CVD
- Improve symptoms CVD
- Control cardiovascular risk factors
- Promote life style changes
- Medication adherence
- Decrease mortality, hospitalizations
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Conclusion
With this overwhelming scientific evidence
supporting the role of cardiac rehabilitation in
secondary prevention of CVD: no excuses not to
refer patients!!!
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Gracias!
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Cardiac Rehabilitation
• Improves Endothelium Function
• Antithrombotic effect
• Peripheral adaptation: skeletal muscles
• Decrease arterial stiffness (protection against
oxidative stress and inflammation
• Enhanced endothelium-dependent vasodilation
(arteries, coronary microcirculation)
•
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Cardiac Rehabilitation:
Benefits
• Autonomic Function:
• increased vagal activity
• attenuated sympathetic hyperactivity
• Increased heart rate variability
• Increased heart rate recovery
• reduced resting pulse
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Cardiac Rehabilitation benefits
Smoking Cessation
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