Focus on Rehabilitation, Exercise and Surgical Coronary Revascularization

Sam Haddad, MDKenneth O’Reilly, MD

Disclosure of Commercial or Pharma Support

• NTD

Heart Failure Guidelines

Learning Objectives

At the conclusion of this workshop, participants will be able to:

•Review the potential role of – Surgical intervention – Exercise and rehabilitation

as heart failure management and treatment options

Surgical Coronary Revascularization

Heart Failure Guidelines

Case 1 • 69 year old male admitted with a diagnosis of HF• Unwell x 3 months, progressive SOBOE and orthopnea

– Denies chest discomfort at any stage

• Past history– HTN – Diabetes diet only– Former smoker– Was treated medically after ACS 2 years ago

• Initial assessment: – BP 120/92, HR 90 bpm (regular), obvious volume overload– NT-BNP 4200 pg/mL, troponin I negative– ECG: sinus rhythm, Q waves leads II,III, AVF, QRS duration 140

msec

Heart Failure Guidelines

Case 1

• Echocardiogram performed:– LVEF ~25%, global hypokinesis– Mild MR– RVSP ~ 45 mmHg

• Course in hospital over 7 days– Diuresed 7 kg with IV furosemide, at “dry weight”– Started on ramipril 5mg/d, and carvedilol 6.25 mg bid

Ambulatory, wondering what we are going to do??

Heart Failure Guidelines

Heart Failure Guidelines

Case 1 - What would you like to do next?

A. Coronary angiogramB. Myocardial perfusion imaging (persantine sestamibi)C. Cardiac MRID. Referral to EP for ICD and or CRT

Heart Failure Guidelines

Back to Case 1

• Angiogram reveals multivessel coronary disease– Occluded RCA– 90% mid LAD lesion– 70% OM1 and 90% OM2 lesions (medium size)

• Surgical colleague reviews the films:– Technically graftable with good distal target vessels

– Serum creatinine stable at 140 mmol/L

Heart Failure Guidelines

Heart Failure Guidelines

Case 1- Your recommended course of action ?

A. Discharge home with a plan for titrated medical therapy only until angina occurs

B. Present the patient to CV surgical colleagues to consider surgical revascularization

C. Refer to interventional colleague for multivessel PCI D. Referral for ICD/CRT

Heart Failure Guidelines

Prognostic significance of ischemic cardiomyopathy

Felker et al, N Engl J Med 2000

>1200 patients with invasive evaluation for cardiomyopathy over 15 years

Ischemic etiology is also an independent predictor of mortality in risk models:

Seattle Heart Failure Model (SHFM)

Heart Failure Survival Score (HFSS)

Levy et al, Circulation 2006Aaronson et al, Circulation 1997

Heart Failure Guidelines

Yusuf et al, Lancet 2004

Individual patient level meta-analysis of 7 trials•2600 patients enrolled 1972-84

•CABG associated with mortality reduction

•39% at 5 years, 17% at 10 years

•No interaction with LV dysfunction and mortality reduction but higher absolute benefits seen in high risk subgroups

Surgical Treatment for Ischemic Heart Failure – where’s the evidence?

Heart Failure Guidelines

• In these early studies:– 90% had angina– 80% had normal LVEF– 10% had arterial conduits– Medical therapy = digoxin and

diuretics

Yusuf et al, Lancet 2004

Surgical Treatment for Ischemic Heart Failure – where’s the evidence?

Need to assess the benefits of revascularization in contemporary patients with ischemic cardiomypathy

Heart Failure Guidelines

Current Era: Surgical Treatment for Ischemic Heart failure (STICH)

Randomized non-blinded study of surgical revascularization:

Included patients with LVEF <35% and CAD suitable for revascularization

Hypothesis 1:CABG + medical rx superior to medical rx alone

Hypothesis 2: CABG + SVR superior to CABG alone in patients undergoing revascularization with anterior wall akinesis/dyskinesis

Velazquez et al, J Thorac and Cardiovasc Surg

Heart Failure Guidelines

STICH Hypothesis 1: Primary outcome

1212 patients randomized to CABG vs medical therapy

Patients with recent MI, major illness, significant L Main disease and severe angina excluded

No difference in all cause mortalityseen at median 56 months follow-up

17% of patients in medical therapy arm crossed over to surgical arm

Heart Failure Guidelines

STICH Hypothesis 1: secondary outcomes

CABG associated with reduction in cardiovascular death and combined outcome of death or cardiovascular hospitalizationCABG also associated with 30% relative reduction in mortality in “on-treatment”analysis (accounting for patients crossing over within 1st year of study)

Heart Failure Guidelines

We recommend that coronary angiography be:

a)Performed in patients with heart failure with ischemic symptoms, who are likely to be good candidates for revascularization.

b)Considered in patients with systolic heart failure (LVEF < 35%) at risk of coronary artery disease, irrespective of angina, who may be good candidates for revascularization.

Strong RecommendationModerate Quality Evidence

Strong RecommendationLow Quality Evidence

Recommendations - Revascularization Procedures

Assessment for Coronary Disease

Heart Failure Guidelines

We recommend consideration of coronary artery bypass surgery for patients with chronic ischemic cardiomyopathy, LVEF < 35%, graftable coronary arteries and who are otherwise suitable candidates for surgery, irrespective of the presence of angina in order to improve quality of life, cardiovascular death and hospitalization.

Strong RecommendationModerate Quality Evidence

Recommendations - Revascularization Procedures

Surgical Revascularization for Patients with IHD and HF

Heart Failure Guidelines

We recommend that performance of coronary revascularization procedures in patients with chronic heart failure and reduced LV ejection fraction should be undertaken with a medical-surgical team approach with experience and expertise in high risk interventions.

Strong RecommendationLow Quality Evidence

Recommendations - Revascularization Procedures

Disease Management, Referral and Peri-operative Care

Values and Preferences:This recommendation reflects the panel preferences that high risk revascularization is likely to

best occur in higher volume centres with significant experience, known outcomes, and similar to participating in clinical trials involving high-risk coronary revascularization.

Practical Tip:Assessment for advanced heart failure therapies by an appropriate team should be performed

prior to revascularization in any patient with advanced heart failure

Exercise Training and Heart Failure

Heart Failure Guidelines

Case

A 74 year old man with ischemic cardiomyopathy

LVEF 33% on echo, mildly dilated LV, MR 1/4

Treatments Candesartan 32mg od, bisoprolol 10 mg od, spironolactone

25 mg od, furosemide 20 mg od ICD for primary prevention since 2003

Stable NHYA II, also limited by bilateral hip pain (OA)

Recent mibi shows no ischemia but an orthopedic surgeon refused to operate on his hips because of his cardiac condition

Heart Failure Guidelines

Heart Failure Guidelines

Regarding exercise in this patient...

A. He left ventricular ejection fraction is too poor to exercise

B. He comorbidities are contra-indications to cardiac rehabilitation

C. He should be referred for cardiac rehabilitation

D. He should not exercise as he has a defibrillator

E. He should be reassured and encouraged to purchase an elliptical trainer

Heart Failure Guidelines

Change in NYHA Class & Kansas City Cardiomyopathy Questionnaire (KCCQ) Score in HFACTION Study

p = 0.03

O’Connor CM et al, JAMA 2009 Flynn et al JAMA 2009

Perc

ent o

f Pat

ient

s

Improved Unchanged Worse

Usual Care Exercise Training * P<0.001 compared to baseline

Chan

ge in

KCC

Q to

tal s

core

at th

ree

mon

ths

NYHA Class KCCQ Score

Heart Failure Guidelines

Potential Mechanisms by Which Exercise Training Improves Outcomes

Organ System/Tissue Response to Exercise Training

Effect on Mortality and Morbidity

Improve CentralTransport and RegionalBlood Flow

↑ in cardiac output; ↑ in peak VO2; reverse chronotropic incompetence; ↑ regional blood flow

↑ peak VO2 →↑ survival;↓ hospitalization

Autonomic NervousSystem

↑ heart rate variability; ↓ plasma norepinephrine (rest)

↑ HRV →↓ arrhythmia→↑ survival,

↓hospitalization↓ plasma NE →↑ survival

Skeletal Muscle

↑ aerobic enzymes; ↑ mitochondria size/density; ↑ capillary density; ↑ relative type I fibers

∆ muscle composition →↑ QOL →↓ hospitalization

Peripheral vasculature ↑ vasculature reactivity↑coronary blood flow →↓ Ischemia and MI →↑ survival, ↓ hospitalization

Heart Failure Guidelines

HF ACTION Study Design

Whellan DJ. Am Heart J 2007.

Chronic heart failure, NYHA Class II-IV, LVEF ≤ 35%,optimal HF medical therapy, capable of exercising

Pre-randomization CPX and ECHO

Randomization 1:1

(Stratified by center and HF etiology)

Exercise TrainingUsual Care

N = 2331Median Follow-up 2.5 years

Supervised exercise(36 sessions)

3d, 30 min 60-70% HRR

Home exercise(months: 3-30)

5d, 40 min 60-70% HRR

Heart Failure Guidelines

All-Cause Mortality or All-Cause Hospitalization

O’Connor CM et al, JAMA 2009* Adjusted for prognostic factors: duration of CPX; LVEF;

Beck Depression score; history A Fib or A Flutter; HF etiology

Heart Failure Guidelines

We recommend that all patients with stable New York Heart Association class I-III symptoms be considered for enrolment in a supervised tailored exercise training program, in order to improve exercise tolerance and quality of life .

Strong RecommendationModerate Quality Evidence

Recommendations - Rehabilitation and Exercise in HFExercise Training in Patients with Heart Failure

Values and Preferences:This recommendation places a high value on improvements in non fatal outcomes and recognizes that not all patients will be able to participate in a structured exercise training program due to patient preferences or availability of resources.

Heart Failure Guidelines

We recommend that an assessment of clinical status by a clinician experienced in the management of heart failure patients be completed prior to considering an exercise training program.

Strong RecommendationLow Quality Evidence

Values and Preferences: This recommendation places a high value on clinician’s assessment of both the clinical stability of a patient and their appropriateness to start exercise, recognizing that most patients will be eligible to participate.

Recommendations - Rehabilitation and Exercise in HFExercise Training in Patients with Heart Failure

Heart Failure Guidelines

How much exercise should you tell the patient to perform?

A. Whatever they feel like because it really doesn’t matter.B. Low intensity exercise so the heart is not stressed.C. Moderate-intensity continuous exercise

(walking/swimming).D. 4. Should be involved only in strength/weight training.

Heart Failure Guidelines

Practical Tips Rehabilitation and Exercise in HF with an ICD

Exercise Prescription and Exercise Modalities in HF

1. Exercise training is safe and not associated with an increased risk of ICD therapy. 2. The maximal target HR should be at least 20 beats below the ICD intervention heart rate to avoid inappropriate ICD shocks.3. For patients with ICD, the devices can be programmed with sinus tachycardia discriminators turned on and patients should be encouraged to monitor HR with a portable device.

Heart Failure Guidelines

Practical Tip Rehabilitation and Exercise in HF

Exercise Prescription and Exercise Modalities in HF

Strength Training

1. For strength training, the use of light (5-10 lbs) free weights for 10-20 repetitions 2 to 3 times per week may improve muscle tone and strength.

Heart Failure Guidelines

Back to Case 1 This man actually underwent hip replacement by

another surgeon after a PET scan showed no ischemia and no significant viability (IMAGE-HF study 1A – Ongoing)

Of note, he had incessant VT under Hawaii blue skies (cruise) in October 2012 (ablated in Honolulu) - without loss of consciousness

Left hip replacement in January 2013

Swimming 4 times a week in April 2013

Right hip replacement December 2013

2014, NYHA class I

Heart Failure Guidelines