Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
Richard A. Josephson MS, MDFACC, FAHA, FACP, FAACVPR
Cardiac RehabilitationIndividualized Healing for Patients
with Cardiovascular Disease
Director of Cardiac Intensive Care Director of Cardiovascular and Pulmonary Rehabilitation
University Hospitals, ClevelandProfessor of Medicine CWRU
Treatment vs. Healing
TREATMENT • The act or manner or an instance of treating someone or something • The techniques or actions customarily applied in a specified situation
HEALING• To become healthy or well again• To make (someone or something) healthy or well again
Miriam Webster Dictionary
CVD Secondary Prevention with Medication
Reduction of BP with a variety of drugsLipid lowering with statinsAntithrombotic treatment with aspirin or clopidogrelBlockade of the RAAS with a variety of agentsBlockade of the SNS with beta blockers
…..are beneficial in a wide spectrum of patients
They each produce, in general, approximately a 15-20 % RRR in CV events over a period of 2-5 years.
Benefits of Cardiac Rehabilitation-ThenMeta-analysis of 32 randomized trials
8440 patients, mean age 55 yrs, >90% maleTrials between 1972-1999, varied regimensExercise-based rehab for patients with CADIssues with methodology, data reporting, changing therapy
Improved LDL, TG, BP, Reduced Tobacco Use
Decreased Mortality:Total mortality OR 0.73 (0.54 – 0.98)CV mortality OR 0.69 (0.51 – 0.94) RRR ~ 30%
Jollife J, et al. Cochrane Database Syst Rev2001
Benefits of Cardiac Rehabilitation-Now
Dramatic Reduction in Mortality
12.2%
5.3%
10.1%
14.8%
19.6%
16.3%
2.2%
5.2%
8.5%
24.6%
0%
10%
20%
30%
0 12 24 36 48 60Months from discharge
Cum
ulat
ive
mor
talit
y ra
te
CR users
Non-CR users
Absolute: 8.3%
Relative: 33.7%
1.1%
3.6%
6.4%
10.0%
14.0%
17.2%
13.1%
9.2%
5.6%
2.6%
0%
10%
20%
30%
0 12 24 36 48 60Months from discharge
Cum
ulat
ive
mor
talit
y ra
te
CR 25 plus sessions
CR 1-24 sessions
More CR is better !
Absolute: 3.2%
Relative: 19%
Cardiac Rehabilitation means a physician-supervised program that furnishes physician prescribed
ExerciseCardiac risk factor modification Psychosocial assessmentOutcomes assessment
Individualized Treatment Plan (ITP) means a written plan tailored to each individual patient that includes
DiagnosisType, Amount, Frequency, Duration of ServicesGoals set for the Individual
Federal Register Vol . 74 No. 226 2009
Exercise is MedicineIncreases
Exercise CapacityCardiac OutputTissue 02 ExtractionV02 MaximumEndothelial FunctionPlasminogenActivatorHDL CholesterolInsulin SensitivityBone MassCognitive Function
Decreases
MortalityRecovery HRResting BPFibrinogenC-Reactive ProteinLDL CholesterolTriglyceridesBody WeightDepressionDisability
UH Cardiac Rehab Program
• Individualized Risk Assessment• Individualized Exercise Prescription• Monitored Exercise (including telemetry)• Educational Program• Access to Smoking Cessation Program• Psychological evaluation and treatment as appropriate• Monitoring of individual patient and goals• Comprehensive discharge prescription• Communication and interaction with physicians
UH Cardiac Rehab Education• Nutrition – lipids, salt, prudent diet, weight loss, label
reading, dining in restaurants• Cardiac anatomy and physiology• Cardiac terms and diagnoses• Cardiac procedures• Cardiac drugs• Smoking cessation• Psychosocial, stress, sex• Work activity• Lifetime healthy lifestyle program
Cardiac Rehabilitation Referral & ITP ProcessPhysician Order for CR CR Team Drafts Initial ITPInpatient or Outpatient
ITP Review and Signatureby Physician
CR Team Drafts 30 Day ITPITP Review and Signature
by Physician
CR Prescriptions/ITPs
Dr. Signature
Dr. Signature
Available via paper, fax, email, AEMR
Cardiac Rehabilitation-Heart FailureMedicare Approval 2014Large Evidence Base Proving Benefit
Exercise Capacity
Quality of Life
LV structural and functional remodeling
Cardiac Rehabilitation-Heart Failure
Systolic HF LVEF < 35%
Optimal medical therapy (unspecified)
Stable on tx for 6 weeks
No planned proceedures (e.g. BivICD, surgery)
Cardiac Rehabilitation-Heart Failure
UH Individualized ApproachMedical Hx, ExamBaseline Multidimensional QuestionnairesCPX TestingExercise Prescription including:
Strength TrainingHigh Intensity Interval Training
Cardiac Rehabilitation-Heart Failure
What about everyone else?• Phase 2-if another qualifying dx
• Phase 3
• Approx $65/month
• Higher staff/pt ratio
Diagnosis Functional Capacity
QOL Morbidity Mortality
AMI +++ +++ ++ +++
CABG Surgery
+++ +++ ++ ++
Chronic Stable Angina
+++ +++ + +
PCI +++ ++ + ?
CHF +++ ++ + +
Cardiac Transplant
+++ ++ ? ?
Heart Valve Surgery
+++ ++ ? ?
Williams MA, et al. Am Heart J 2006;152:835-41
Benefits of Cardiac Rehabilitation
Evidence for Cardiac RehabilitationCurrent ACC/AHA Guidelines
• Post CABG• STEMI• NSTEMI• Stable Angina• PCI• Heart Failure
• Class I, Level B• Class I, Level C• Class I, Level B• Class I, Level B• Class I, Level B• Class IIa, Level B
ACC/AHA Clinical Practice Guidelines
Case CR PRChagrin CR PRConneaut CR PRElyria CR PRGeauga CR PRMentor CR PRParma CR PR
UH Cardiovascular & Pulmonary Rehabilitation
ReferencesKing M, Bittner V, Josephson R, Lui K, Thomas RJ, Williams MA., Medical Director Responsibilities for Outpatient Cardiac Rehabilitation/Secondardy Prevention Programs: 2012 Update: A Statement for Health Care Professsonals from The American Association for Cardiovascular and Pulmonary Rehabilitation and The American Heart Association. Circulation. 2012 Nov 20; 126 (21): 2535-43. PubMed PMID: 23091064.
Josephson, R, and J. Weingart, “Cardiac Rehabilitation” Update to Chapter 67 “Rehabilitation of the Patient with Coronary Heart Disease”. Fuster, V., O’Rourke, R. A., Walsh, R. A., Poole-Wilson, P,, Editors, King, S. B., Roberts, R., Nash. I. S., Prystowsky, E. N., Associate Editors: Hurst’s The Heart, 12th Edition: July 2010. htttp://www.accessmedicine.com/updatesContent.aspx?aid=1001647.
Cochrane Database Syst Rev. 2014 Apr 27;4:CD003331. doi: 10.1002/14651858.CD003331.pub4.Exercise-based rehabilitation for heart failure.Taylor RS1, Sagar VA, Davies EJ, Briscoe S, Coats AJ, Dalal H, Lough F, Rees K, Singh S.
Cardiac Rehabilitation and Secondary Prevention of Coronary Heart Disease, Philip A. Ades, M.D., N Engl J Med 2001; 345:892-902September 20, 2001DOI: 10.1056/NEJMra001529
Carl J. Lavie, Richard V. Milani. (2011) Cardiac Rehabilitation and Exercise Training in Secondary Coronary Heart Disease Prevention. Progress in Cardiovascular Diseases 53:6, 397-403
JAMA. 2009 Apr 8;301(14):1439-50. doi: 10.1001/jama.2009.454.Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial.O'Connor CM1, Whellan DJ, Lee KL, Keteyian SJ, Cooper LS, Ellis SJ, Leifer ES, Kraus WE, Kitzman DW, Blumenthal JA, Rendall DS, Miller NH, Fleg JL, Schulman KA, McKelvie RS, Zannad F, Piña IL; HF-ACTION Investigators.
�