Heart Disease! UCLH Trust Members 2010

1. Heart Disease!UCLH Trust Members 2010 Dr Malcolm Walker Consultant Cardiologist UCLH & the Heart Hospital

2. Dr Malcolm Walker • Consultant Cardiologist - general adult interventional cardiologist with special interests in rehabilitation and myocardial iron overload • Director of Hatter Cardiovascular Institute UCH • Immediate past president British Association of Cardiovascular Rehabilitation (BACR) • Scientific board member of the Thalassaemia International Federation (TIF – a WHO sponsored NGO - a patients & families lobby)

3. Question • “What treatment has randomised trial evidence of long term benefit by mortality reduction of >20%, morbidity reduction of a similar magnitude, causes weight loss, reduces blood pressure, improves mood, improves functional capacity, raises HDL cholesterol, improves glucose metabolism and does not cost the earth?”

4. Heberden 1772 • “one patient nearly cured himself of his angina” by retreating to his country estate “and sawing wood every day for some months”

5. Case history: June 2003 59 yr old male Collapse – Rx DCC CPR Urgent angiography Urgent CABG

6. Case history: June:Emergency CABG October ….. 7 Marathons in 7 days

7. Does fitness affect survival ? • After Myocardial infarction • In primary prevention

8. Cooper Clinic experienceBlair et al JAMA 1989 % Dead Category of Fitness from 1 (low) to 5 (very fit)

9. Does fitness affect survival ? • After Myocardial infarction • In primary prevention

10. Harvard alumni study

11. Harvard alumni study

12. Harvard alumni - summary • Self reported Borg-type scale useful • Graded benefit according to amount of exercise, when compared to those not doing any So not everybody has to wear lycra pants & join a gymnasium • Limitations of the study: • Men, American, higher social class

13. Walking – benefit to high risk group demonstrated • Decreased death rate in diabetics • 2896 adults with diabetes • Those walking >2hr per week • 39% lower all cause mortality • 34% lower cardiovascular mortality • Largest benefit in those walking 3-4hr per week and for those reporting moderate increase in heart rate & breathing rate Arch Intern Med 2003; 163: 1440-1447

14. Exercise as therapy in CHD BUT can we provide an intervention that works?

15. Cardiac Rehabilitation • The patients can do more • Their cholesterol is lower • They are taking their tablets regularly • They are no slimmer Is anything more being achieved for them?

16. Cardiac Rehabilitation in CHD • Taylor, R.S. et.al. Am J Med 2004 • Hospitalised for CHD • 48 RCTs, n= 8940 • 20% reduction in all cause mortality 24% in cardiovascular mortality • Gains still evident when statins given to both arms of trial

17. So exercise does matter • Both for “victims” of CHD and as a method of prevention

18. Cardiovascular Rehabilitation • Why? • Because there is good evidence that it helps • Because we’ve been told to..

19. NSF CHD – Cardiac Rehabilitation • Chapter 7 (Standard 12) “NHS Trusts should put in place agreed protocols/systems of care so that, prior to leaving hospital, people admitted to hospital suffering from coronary heart disease have been invited to participate in a multidisciplinary programme of secondary prevention and cardiac rehabilitation.” • NSF Goal “Every hospital should ensure • that more than 85% of people with a primary diagnosis of AMI are offered cardiac rehabilitation.

20. Cardiovascular Rehabilitation • Why? • Because there is good evidence that it helps • Randomised control trial (RCT) data • Because we’ve been told to.. • NSF • Because there is an unmet need

21. % Eligible patients offered CR England & Wales Surveys by Dr Hugh Bethel – BACR/BHF

22. University College Hospital Foundation TrustCardiovascular Health & Rehabilitation • 2005 Co-operative bid with Camden PCT for BHF NOF funding – Grant £120,000 • To develop a new self management method to deliver CR in association with Prof Stan Newman • Aims to reduce DNA rates • Improve adoption & maintenance of behaviour change • Plan to roll out to whole sector & beyond if successful

23. UCH Cardiovascular Health & Rehabilitation • Patient recruitment • Heart Hospital • Cardiology patients identified from cath. lab database • All receive standard letter or contacted by telephone • Camden patients reviewed whilst in-patients – if time • N.B. all Heart hospital patients (90+) are eligible for CR! • Surgical patients referred by surgical audit team • UCH • Daily ward round AAU – most eligible patients will transfer to Heart Hospital

24. Number of Patients referred to CR Currently represents between 88-92 % of eligible patients

25. Number of patients referred for CR at UCH CV Health

26. UCH Cardiovascular Health & Rehabilitation

27. UCH Cardiovascular Health & Rehabilitation • Important service characteristics • Close liaison with sector – rehabilitation task group • Evidenced by Patient choice funding & Combined BHF NOF bid • Strategic alliance with central YMCA 2003 • Exercise classes move out of hospital environment • Exercise professionals supported through BACR training • Flexibility – timing, course structure & content • Menu of choices for patients • Early adoption of national (BACR/ BHF/ York University) minimum dataset • Introduction of self-management programme

28. UCH Cardiovascular Health & Rehabilitation • New developments • Expanded remit • Heart failure – initially from hospital clinics, expanding to offer to primary care – now in full swing • “Primary” prevention in diabetics – initially from hospital clinic with a view to expand to primary care – supports existing initiative of Camden Active Health Team • Improve accessibility • Walk in assessment service – as per R1 • Pilot with one local primary care provider in first instance

30. Conclusions on Cardiovascular Rehabilitation • Task worth the effort • CR evidence is compelling • Anecdotal experience will amplify! • Individuals committed to the service • Trained to deliver high quality CR – use BACR/ ACPIR resources • Good quality data • National CR audit makes this easier • Simple local databases are a starting point – get your kids to design you one! • Good quality communication • Fax, telephone, e-mail ! • CR administrator invaluable/ sine qua non ? It’s mostly about teamwork!