After modern CABG: Pro.

Transcription

1 Is there a role for cardiac rehabilitation in the modern era of PCI and CABG? After modern CABG: Pro. Massimo F. Piepoli, Italy No conflict of interest

2 Modern CABG: MICS CABG (Minimally Invasive Cardiac Surgery)

3 Modern CABG: MICS CABG (Minimally Invasive Cardiac Surgery) Less pain Lower risk of wound infection Fewer restrictions, Faster recovery Improved cosmetic outcome

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5 interventionalist and cardiac surgeon may fix the lesions, but treatment should not end when patients leave the cath lab or the theatre Now you are fine: the next one please

6 ...when patient experiences a CAD event Whitewaters he/she enters rapids a period of time that is high risk, life threatening and life altering the medical equivalent of a ride down the turbulent and dangerous whitewater rapids portion of a river Randal Thomas

7 Italian Society of Cardiac Surgeons: Annual Report Age distribution of CABG patients Age (years)

8 Italian Society of Cardiac Surgeons: Annual Report Age Co-morbidities Severity Female Age <50 <60 >70 Hypertension NIDD IDD Vasculo-pathy COPD Hepato-pathy Chronic renal disease Dialysis Obesity Cachessia Chronic CAD Diagnosis - silent ischemia - stable angina - unstable angina - AMI - other Three vessel or LM LVEF<35 Acute case Acute + Emergency Mortality Colombo Ital Heart J Suppl 2004; 5(5)

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10 CABG+Mitral R. CABG+Aortic R. CABG In hospital mortality after cardiac surgery J Am Coll Cardiol 2000

11 Modern CABG Ideal Real World

12 The answer: Cardiac Rehabilitation

13 Diagnosis Fxnl. Capacity QOL Morbidity Mortality AMI CABG Stable angina PCI ? CHF Cardiac Transplant Valve Repl. The Evidence Fewer events, reduced all cause mortality 20-34% ?? ?? Am Heart J. Nov (5):835-41

14 Cochrane Database Syst Rev. 2010

15 Cochrane Database Syst Rev Jul 6;(7):CD001800

16 Reduction of event rate after cardiac rehabilitation: comparison between PCI and CABG patients Hansen D. et al. Acta Cardiologica 2009

17 Reduction of event rate after cardiac rehabilitation: comparison between PCI and CABG patients Hansen D. et al. Acta Cardiologica 2009

18 Reduction of event rate after cardiac rehabilitation: comparison between PCI and CABG patients Hansen D. et al. Acta Cardiologica 2009

19 Reduction of event rate after cardiac rehabilitation: comparison between PCI and CABG patients Hansen D. et al. Acta Cardiologica 2009 P<0.05 rehab vs control for PCI and CABG P<0.05 rehab vs control for CABG

20 Cost-Effectiveness Therapy 8 week Cardiac Rehab program Statin therapy in secondary prevention $/year of life saved 4,950 9,630 CABG 18,700 Thrombolytic therapy in AMI 32,700 Am J Cardiol

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22 Cardiac Rehabilitation

23 Myocardial revascularization must be accompanied by adequate secondary prevention strategies: OMT, risk factor modification, and permanent lifestyle changes. Cardiac rehabilitation and secondary prevention are an essential part of long-term management after revascularization because such measures reduce future morbidity and mortality, in a cost-effective way. Joint 2010 ESC - EACTS Guidelines on Myocardial Revascularisation

24 Patients require counselling to adopt a healthy lifestyle and encourage adherence. Key role of the interventional cardiologist and cardiac surgeon Therapy should be initiated during hospitalization Adherence to risk factor modification requires individualized behavioural education Education interactive with full participation of caregivers Adherence to the prescribed recommendations and the goals achievement should be regularly evaluated Joint 2010 ESC - EACTS Guidelines on Myocardial Revascularisation

25 Cardiac Rehabilitation Components: Joint 2010 ESC - EACTS Guidelines on Myocardial Revascularisation

26 Safety Clinical and risk assessment Surgery complications Sedentary habits, Occupational and recreational needs Exercise testing modality Joint 2010 ESC - EACTS Guidelines on Myocardial Revascularisation

27 patients who survive a CAD without Cardiac Rehab can be compared with a people that are crossing the whitewater rapids without a raft... Randal Thomas Raft

28 Modern CABG Ideal Real World P<0.05 rehab vs control for PCI and CABG Therapy $/year of life saved 8 week Cardiac Rehab 4,950 Statin therapy in secondary 9,630 CABG 18,700 Thrombolytic therapy in AMI 32,700

29 thanks