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THE CARDIOLOGY CONNECTION GUIDELINES FOR PREVENTION OF DISEASE PROGRESSION Peter K. Shaw, MD, FACC October 12, 2005 The Problem CAD -- leading cause of death and disability in U.S. among men and women Huge numbers: In 1997: AMI diagnosis in 1.1 million people

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the cardiology connection

THE CARDIOLOGY CONNECTION

GUIDELINES FOR PREVENTION OF DISEASE PROGRESSION

Peter K. Shaw, MD, FACC

October 12, 2005

the problem
The Problem
  • CAD -- leading cause of death and disability in U.S. among men and women
  • Huge numbers: In 1997:
    • AMI diagnosis in 1.1 million people
    • > 0.8 million revascularization procedures
  • Prevention of subsequent events and enhancement of physical function in patients have immense impact
cardiac rehabilitation
Cardiac Rehabilitation
  • Before the mid-20th C., treatment of MI:
    • 3 weeks of bedrest
    • Out of work up to 6 months, if work was to be permitted
    • Little understanding about the pathophysiology, causes, appropriate treatment, and prevention of subsequent events
  • Chair therapy: a major and courageous breakthrough!
cardiac rehabilitation 2
Cardiac Rehabilitation-2
  • Programs 1st developed in 1960s
  • Benefits of ambulation recognized
    • Safer in supervised environment than at home
    • Developed into highly structured, physician and nurse-supervised, ECG monitored programs
    • Focus primarily on exercise (as medicine)
      • Dosage
      • Frequency
      • Intensity
cardiac rehabilitation 3
Cardiac Rehabilitation-3
  • Hospital stays for MI and ACS 3-5 days
    • Reduced deconditioning
    • However, reduced opportunity for patient education
  • Regular exercise and risk factor modification reduce morbidity and mortality of CHD
  • Cardiac Rehab: assessment and modification of risk factors--> Secondary-prevention centers
cardiac rehabilitation 4
Cardiac Rehabilitation-4
  • Exercise after MI: reduced overall and cardiac causes of mortality
  • Decreased rates of subsequent coronary events and hospitalizations
  • More efficient and effective than individual physician care: most care providers:
    • not fully trained in cardiac rehab techniques
    • inadequate time for effective nutritional advice, weight mgmt, exercise prescription
cardiac rehabilitation 5
Cardiac Rehabilitation-5
  • Appropriate subjects:
    • AMI
    • Coronary revascularization
    • Chronic stable angina pectoris
    • CHF
    • Post cardiac transplant
  • Goals:
    • Prevent disability
    • Prevent subsequent coronary events
exercise training
Exercise Training
  • Cardiac arrest: 1/112,000 patient-hours
  • Non-fatal MI: 1/294,000 patient-hours
  • Mortality: 1/784,000 patient-hours
  • Exercise capacity:(aerobic conditioning, 3x/wk, over 3 mo)
    • increase by 30-50%
    • peak O2 consumption inc. 15-20%
    • Subjective improvement in performance of ADLs (climbing stairs, carrying groceries)
  • Higher angina threshold due to lower HRxBPs product as a result of aerobic conditioning
  • Physiologic adaptations are both central (cardiac) and peripheral (skeletal muscle and vascular)
the bottom line
The Bottom Line
  • Long-term mortality from CV and all causes (meta-analyses ‘70s-’80s)
    • Cardiac rehab w/ 25% reduction in overall and CV mortality over 3 years
  • Why?
    • Improved lipids
    • Improved coronary blood flow
    • Reduced obesity
    • Improved HR variability and autonomic tone
    • Increased fibrinolysis
    • Improvement in psychological factors
  • EXERCISE TRAINING IMPROVES FNL CAPACITY, REDUCES SXS IN PTS W/ CAD, & REDUCES OVERALL AND CV MORTALITY
cardiac rehab in dm 2
Cardiac Rehab in DM-2
  • Ongoing drug therapy (insulin, oral hypoglycemic agents) and need for exercise-related dose adjustments
  • Techniques of self-monitoring have become essential to pursue effective and safe exercise rehabilitation
  • Complications (retinopathy, neuropathy, nephropathy) all affect exercise prescription
  • Higher prevalence of silent ischemia requires careful monitoring
benefit in type 2 dm
BENEFIT IN TYPE 2 DM
  • 59 DM2 pts (vs 36 age-matched non-DM controls)
  • 2 month program after acute coronary event
  • After program, improvement in exercise capacity lower in diabetic pts
  • In pts with DM, significant inverse relation btw FBS and change in peak VO2
  • Thus, degree of glycemic control may have important implications in success of exercise rehabilitation in this cohort.
  • Verges, et al. Diabet Med. 2004 Aug:21 (8): 889-95
results of cardiac rehab in pts with dm
RESULTS OF CARDIAC REHAB IN PTS WITH DM
  • In 2003 study, 26% of pts in a program at Boston Medical Ctr. had DM
    • 53% taking insulin &/or oral hypoglycemic medication
  • Greater risk profile, with higher prevalence of
    • hypertension -PVD
    • obesity -lower ex. Capacity
  • Initial Hgb A1C 8.4%
  • Fewer DM pts completed program (38% vs 48%)
    • exacerbation of medical problem (both cardiac and noncardiac) cause of dropout (29% vs. 18%)
  • Banzer et al., AmJCard 93 (1) 2004 Jan1 (81-84)
approach to involvement of diabetic patient in cardiac rehabilitation
APPROACH TO INVOLVEMENT OF DIABETIC PATIENT IN CARDIAC REHABILITATION
  • At intake appt, nurse card mgr reviews program guidelines with participant and involves PCP re: medication or diet adjustments before starting program
  • Classroom “Diabetes 101” review of diabetic guidelines for exercise
  • Participants encouraged to bring their own monitors (checked for accuracy by Program Monitor…+/- 20% acceptable accuracy)
  • BG monitored 15-30 min prior to exercise, and post-exercise for at least 3 sessions
  • If BG out of range, set protocol for intervention and consultation with PCP
treatment of hypoglycemia
TREATMENT OF HYPOGLYCEMIA
  • 50-100 mg/dl: 15 gm CHO; repeat BG testing after 15 minutes. May exercise when BG >120 mg/dl
  • <50 mg/dl: 30 gm CHO. Consider glucagon. Repeat BG testing after 15 minutes. Repeat CHO until BG >120 mg/dl and free of hypoglycemic sxs.
value of cardiac rehabilitation in dm
VALUE OF CARDIAC REHABILITATION IN DM
  • The participant understands the importance of regular exercise as part of a comprehensive medical management strategy: “EXERCISE IS MEDICINE”
  • Establishes a habit and a rhythm of regular participation
  • Teaching safe methods of exercise
    • avoidance of pre- or post-exercise hypoglycemia
    • encourages choice of exercise appropriate to particular condition (neuropathy, retinopathy, nephropathy)
    • Encourages frequent testing as guide to safe approach
  • Participant understands diabetes as part of a collection of coronary risk factors--inspires patient to take responsibility for own medical condition
effects on coronary risk factors
Effects on Coronary Risk Factors
  • Lipids: 8-23% increase in HDL
  • Increase of chol/HDL = 5-26%
  • However, exercise training alone:
    • Minimal effect on LDL
    • 0-2% change in body wt at 3 months
      • -5% fat mass, +2% muscle mass
    • Improved glucose tolerance and less insulin resistance
exercise prescription
Exercise Prescription
  • Consider risk factors, age, functional status
  • Moderate to high intensity, 3-5x/wk, 25-45 min per session
  • Low caloric expenditure: 270-283 kcal/session, not likely to induce wt loss without dietary changes
  • Regimen of low-intensity, prolonged daily exercise (“high caloric training”) leads to greater fat loss than more intense briefer sessions
  • Important to include resistance training to minimize loss of muscle mass
  • Intervals of relatively intense exercise may lead to improvement in endothelium-dependent coronary vasodilation after 4 wks.
summary of components and goals
Summary of Components and Goals
  • Initial history and physical examination
  • Control hypertension
  • Smoking cessation
  • Weight loss if BMI > 25
  • DM control
  • Psychosocial adjustments
  • Physical activity counseling and exercise prescription and training
  • Enhance compliance:
    • Exercise: 50% at one year --anti-htn meds: 64%
    • lipid-lowering meds: 82% --f/u necessary after program
comprehensive risk reduction
Comprehensive Risk Reduction
  • Smoking: decision to stop is central
    • Unequivocal message from health professionals
    • Pick a date --Involve important others
    • Behavioral skills for coping with stress, possible use of bupropion &/or nicotine supplements
    • Followup
  • Hyperlipoproteinemia
    • Diet --Medications --Exercise --Followup
comprehensive risk reduction 2
Comprehensive Risk Reduction-2
  • Weight-loss
    • May lead to 4-9% reduction when exercise w/ dietary intervention
    • Improved lipid levels, insulin resistance, BP, clotting abnormalities
    • Stimulus control (behavioral changes)
    • Self-monitoring
    • Social support (non-judgmental)
    • Daily calorie count and recording
    • 5-10% reduction in bw may be sufficient to improve lipids and insulin resistance
comprehensive risk reduction 3
Comprehensive Risk Reduction-3
  • BP and DM-2 benefited by exercise training, weight loss, and improved diet
  • Self-monitoring of BP and DM important skills to learn; will help PCP management
  • Psychological Factors:
    • Cardiac rehab improves measures of
      • anxiety + emotional stress +self-confidence
      • depression +social isolation +quality-of-life
challenges
Challenges
  • Extension of services to indigent and uninsured
  • Geographic issues, especially in rural states
  • Reaching appropriate patients:
    • In hospital screening and recruitment
    • Prioritize communication and involvement of cardiologist and PCP for referral and close followup
  • Individualize programs
    • to be appropriate for elderly, younger patients, the physically challenged, and the remotely situated
    • risk-factor modifications appropriate for each case
    • emphasize the payoff: physical, behavioral, and risk-factor changes that will lead to improved outcomes
helpful resources
Helpful Resources
  • Philip A. Ades, MD, Cardiac Rehabilitation and Secondary Prevention of Coronary Heart Disease NEJM 2001; 345:892-902.
  • Wenger, NK et al, Cardiac rehabilitation: clinical practice guidelines, 1995 (AHCPR publication no. 96-0672)
  • DeBusk, RF, et alCase-mgmt system for coronary risk-factor modification after AMI Ann Int Med 1994: 120: 721-729
  • Linden W, et alPsychosocial interv for pts w cad: meta-analysis Arch Int Med 1996; 156: 745-752