Secondary Prevention & Cardiac Rehabilitation

Malcolm Walker

Consultant Cardiologist

UCLH & the Heart Hospital, London

Malcolm Walker

NO CONFLICT OF INTEREST TO DECLARE

COURAGE Trial

When the PCI is over, what else could there possibly be left to do?

J Am Col Cardiology. 2008; 52: 889-893

Patients with significant coronary stenoses are at increased risk of future cardiac events. However, in the absence of acute coronary syndrome or recent MI and residual ischemia, elective PCI has not been shown to improve prognosis.

Reviews of Exercise Based Rehabilitation

Reviews No. of RCTs

No. of Patients

Meta-analysis

Relative Reduction in Total Mortality

Exerciseor Exercise plus CR

Oldridge 1988O’Connor 1989Bobbio 1989

10

9

8

4347

4554

2260

Yes

Yes

Yes

24% (8 to 37%)

20% (4 to 34%)

32% (14 to 47%)

Cochrane Review: Joliffe et al. 2000

8440 patients after MI or Revascularisation

Exercise only: 27% fall in all cause mortality; 31% fall in cardiac mortality

Exercise + : 13% fall in all cause mortality; 26% fall in cardiac mortality

• 2004 Metanalysis• 48 RCTs, n= 8940• Patients hospitalised for CHD• Conclusion: 20% reduction in all cause

mortality 24% in cardiovascular mortality

Cardiac Rehabilitation - the Statin era

Taylor, R.S. et.al. Am J Med 2004

Walther et.al. Eur J Cardiovasc Prev Rehabil. 2008; 15: 107-112

Hambrecht group – Event-free survival in exercise versus PCI groups at 24 months

hs CRP levels at Baseline & 24 Months

0

0.5

1

1.5

2

2.5

3

3.5

Exercise Group PCI Group

Baseline

24 months

p = 0.025

p = ns

Walther et.al. Eur J Cardiovasc Prev Rehabil. 2008; 15: 107-112

How might exercise improve CAD outlook

• Improved associated cardiovascular risk factors

– Improved physical fitness– Weight– Diabetes– HDL levels– Adherence to improved diet– Reduced smoking– Improved compliance with medication– Markers of inflammation: e.g. hs CRP– Endothelial function

• 2008• 213 patients post PCI• Non-randomised: 133 received CR, 80

no CR• Mean follow-up 4.5yr• Results:

• Readmission for CAD event 45% CR vs 75% no CR

• Revascularisation 7% CR vs 17% no CR• Total health care cost: 4862 Eu/pt vs 5498

Eu/pt• 15/12 MACE 24% CR vs 42% no CR P<0.005

Cardiac Rehabilitation (CR) - after PCI

Dendale P. et.al. Acta Cardiol 2008

Core components of CR

95%94%

71%73%78%77%

94% 94%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Aspirin ACEi Beta-block Statin

Before CR

After CR

NACR Annual Statistical Report: 200812 week Medication Record

73% 74%

36%

56%

13%8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

BMI < 30 Exercise Smoker

Before CR

After CR

NACR Annual Statistical Report: 200812 month outcome (NSF Targets)

NACR Annual Statistical Report:Reasons for referral to CR 2006-2007

56%

7%

14%

18%4% 1%

MI

ACS

CABG

PCI

Angina

CCF

NACR Annual Statistical Report:2008Percentage Eligible Patients Who Receive CR in

England

42%

73%

31%

0%

10%

20%

30%

40%

50%

60%

70%

80%

MI CABG PCI

MI

CABG

PCI

Barriers to CR

• Speed of throughput– Tertiary centre syndrome

• Not my responsibility– The nurses will do it– It’s primary care’s job

• Patient reluctance the “Andy Capp syndrome”

Well Mr Capp, just have the PCI

Overcoming the Barriers to CR

• Local CR programmes have to be– Accessible– Flexible– Responsive– Visible– Provide CR to a level known to improve

prognosis• Cardiologists have to take responsibility for

the complete “package” of care… or assume the role of cardiac interventional radiologists

Can we see a time when all PCI patients from CR?

Dream on