Cardiac Rehabilitation Individualized Healing for Patients with Cardiovascular Disease

Transcription

1 Cardiac Rehabilitation Individualized Healing for Patients with Cardiovascular Disease Richard A. Josephson MS, MD FACC, FAHA, FACP, FAACVPR Director of Cardiac Intensive Care Director of Cardiovascular and Pulmonary Rehabilitation University Hospitals, Cleveland Professor of Medicine CWRU

2 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

3 CVD Secondary Prevention with Medication Reduction of BP with a variety of drugs Lipid lowering with statins Antithrombotic treatment with aspirin or clopidogrel Blockade of the RAAS with a variety of agents Blockade of the SNS with beta blockers..are beneficial in a wide spectrum of patients They each produce, in general, approximately a % RRR in CV events over a period of 2-5 years.

4 Benefits of Cardiac Rehabilitation-Then Meta-analysis of 32 randomized trials 8440 patients, mean age 55 yrs, >90% male Trials between , varied regimens Exercise-based rehab for patients with CAD Issues with methodology, data reporting, changing therapy Improved LDL, TG, BP, Reduced Tobacco Use Decreased Mortality: Total mortality OR 0.73 ( ) CV mortality OR 0.69 ( ) RRR ~ 30% 2001 Jollife J, et al. Cochrane Database Syst Rev

5 Benefits of Cardiac Rehabilitation-Now Dramatic Reduction in Mortality 30% CR users Non-CR users 24.6% 30% CR 25 plus sessions CR 1-24 sessions Cumulative mortality rate 20% 10% 0% Absolute: 8.3% Relative: 33.7% 5.3% 2.2% 10.1% 5.2% 14.8% 8.5% 19.6% 12.2% Months from discharge 16.3% Cumulative mortality rate 20% 10% 0% More CR is better! Absolute: 3.2% Relative: 19% 2.6% 1.1% 5.6% 3.6% 9.2% 6.4% 13.1% 10.0% 17.2% Months from discharge 14.0%

6 Cardiac Rehabilitation means a physician-supervised program that furnishes physician prescribed Exercise Cardiac risk factor modification Psychosocial assessment Outcomes assessment Individualized Treatment Plan (ITP) means a written plan tailored to each individual patient that includes Diagnosis Type, Amount, Frequency, Duration of Services Goals set for the Individual Federal Register Vol. 74 No

7 Exercise is Medicine Increases Exercise Capacity Cardiac Output Tissue 02 Extraction V02 Maximum Endothelial Function Plasminogen Activator HDL Cholesterol Insulin Sensitivity Bone Mass Cognitive Function Decreases Mortality Recovery HR Resting BP Fibrinogen C-Reactive Protein LDL Cholesterol Triglycerides Body Weight Depression Disability

8 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

9 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

10 Cardiac Rehabilitation Referral & ITP Process Inpatient or Outpatient Physician Order for CR CR Team Drafts Initial ITP ITP Review and Signature by Physician CR Team Drafts 30 Day ITP ITP Review and Signature by Physician

11 CR Prescriptions/ITPs Dr. Signature Dr. Signature Available via paper, fax, , AEMR

12 Cardiac Rehabilitation-Heart Failure Medicare Approval 2014 Large Evidence Base Proving Benefit Exercise Capacity Quality of Life LV structural and functional remodeling

13 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)

14 Cardiac Rehabilitation-Heart Failure UH Individualized Approach Medical Hx, Exam Baseline Multidimensional Questionnaires CPX Testing Exercise Prescription including: Strength Training High Intensity Interval Training

15 Cardiac Rehabilitation-Heart Failure What about everyone else? Phase 2-if another qualifying dx Phase 3 Approx $65/month Higher staff/pt ratio

16 Benefits of Cardiac Rehabilitation Diagnosis Functional QOL Morbidity Mortality Capacity AMI CABG Surgery Chronic Stable Angina PCI ? CHF Cardiac Transplant Heart Valve Surgery ?? ?? Williams MA, et al. Am Heart J 2006;152:835-41

17 Evidence for Cardiac Rehabilitation Current 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

18 UH Cardiovascular & Pulmonary Rehabilitation Case CR PR Chagrin CR PR Conneaut CR PR Elyria CR PR Geauga CR PR Mentor CR PR Parma CR PR

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20 References King 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 Nov 20; 126 (21): PubMed PMID: 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, 12 th Edition: July htttp:// Cochrane Database Syst Rev Apr 27;4:CD doi: / CD 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: September 20, 2001DOI: /NEJMra Carl J. Lavie, Richard V. Milani. (2011) Cardiac Rehabilitation and Exercise Training in Secondary Coronary Heart Disease Prevention. Progress in Cardiovascular Diseases 53:6, JAMA Apr 8;301(14): doi: /jama 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.