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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 l.jpg



Peter K. Shaw, MD, FACC

October 12, 2005

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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

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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!

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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

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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

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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

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Cardiac Rehabilitation-5

  • Appropriate subjects:

    • AMI

    • Coronary revascularization

    • Chronic stable angina pectoris

    • CHF

    • Post cardiac transplant

  • Goals:

    • Prevent disability

    • Prevent subsequent coronary events

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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)

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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


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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

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  • 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

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  • 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)

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  • 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

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  • 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.

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  • 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

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Effects on Coronary Risk Factors REHABILITATION

  • 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

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Exercise Prescription REHABILITATION

  • 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.

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Summary of Components and Goals REHABILITATION

  • 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

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Comprehensive Risk Reduction REHABILITATION

  • 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

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Comprehensive Risk Reduction-2 REHABILITATION

  • 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

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Comprehensive Risk Reduction-3 REHABILITATION

  • 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

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  • 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

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Helpful Resources REHABILITATION

  • 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