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Benefits of Cardiac Rehabilitation: Impact on Mortality, Hospitalizations and Risk Factors

Benefits of Cardiac Rehabilitation: Impact on Mortality, Hospitalizations and Risk Factors. Reggie Higashi, MSS Exercise Physiologist. Core Program Components. Baseline clinical evaluation & patient assessment Risk factor management and goal setting Psychosocial management

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Benefits of Cardiac Rehabilitation: Impact on Mortality, Hospitalizations and Risk Factors

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  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; 102:1069-1073.

  3. Approved Diagnoses(Medicare) • Myocardial infarction • Within 1 year • Stable angina • Coronary artery bypass grafting • Within 1 year Ref: Section 35:25 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, 8:00 a.m. - 9:00 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) 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 • < 62 yrs: 46% utilization • > 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 • > 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 Factors:Cholesterol 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, > 12 weeks of training

  19. Impact on Risk Factors:Diabetes 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 Factors:Blood Pressure Reduction 44 Trials, n = 2,674

  21. Impact on Risk Factors:Smoking • 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 Factors:Weight Reduction

  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

  26. Summary:Benefits 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 today’s lecture. Any Questions???

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