Is cardiac rehabilitation necessary?

Transcription

1 Is cardiac rehabilitation necessary? M. Ghannem CPRCV Ollencourt Léopold Bellan UCI - CH Gonesse

2 No conflic of interest

3 Is cardiac rehabilitation necessary? Is cardiac rehabilitation recommended.

4 Is coronary revascularisation STEMI nécessary?

5 Percentage of deaths at 30 days Evolution of mortality at 30 days according to the method and type of reperfusion No reperfusion Thrombolysis Coronary angioplasty FAST- MI 2012

6 Guidelines from the Européen Society of Cardiology 2012 Coronary revascularisation STEMI Is nécessary

7 Is réhabilitation After STEMI nécessary?

8 FAST MI 2005 ( 5 - year survival) 3670 patients réhabilitation No réhabilitation (20%) Iliou MC, Danchin N. AHA 2012

9 Participation in Cardiac Rehabilitation, Readmissions, and Death After Acute Myocardial Infarction 2991 STEMI + ( ) : 52% patients rehabilitation Mortality: - 42% Dunlay S Am J Med (2014) 127,

10 Guidelines from the Européen Society of Cardiology 2012 ESC 2012 STEMI

11 Guidelines from the French Society of Cardiology 2010 CAD (except surgery) Class Level ACS «stabilized» - Exercise evaluation -Secondary Prevention -Therapeutic Education -Ambulatory if possible I A After scheduled angioplasty -Exercise evaluation -Not over-risk -Secondary Prevention -Therapeutic Education -Ambulatory if possible I B Stable angina -Exercise evaluation -Therapeutic Optimisation I B -Secondary Prevention -Therapeutic Education -Ambulatory if possible

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13 Percentage of patients with STEMI Change in practice: reperfusion of patients with STEMI* years PCI increase : 12% à 61% Réhabilitation : 20 à 30 % No revascularisation : 25 % No Réhabilitation : 70% FAST- MI 2012

14 ..

15 EXERCISE ECG

16 Safety 3132 patients with coronary stenting within the last 12 months 44 cardiac centres réhabilitation.. Iliou MC. Eur J Prev Cardiol 2015;22:27-34

17 Survie sans événements cardiovasculaires Post ATL + ou - readaptation 108 Patients à 3 ans Réadaptation Contrôle BELARDINELLI R, J Am Col Cardiol 2001; 37 :

18 Impact Of Cardiac réhabilitation on Mortality and Cardiovascular Events After PCI 2395 pts PCI 1994 to 2008 Follow -op 6.3 years 40% Cadiac réhabilitation 45 % overall mortality 31 % cardiac mortality 27 % Death or MI Goel K, Circulation 2011;123:

19 Stenting, physical training (PT) and endothelial function PT: % T : % P : 0.01 Munk et al Am Heart J Nov; 158(5) :

20 Survival After Coronary Artery Bypass Graft Surgery 846 pts, 69 % CR Follow op 10 years, RR réduction in all cause mortality 46 % Absolute risk reduction of 12.7% Quinn R. Pack. Circulation. 2013; 128:

21 failure : patients profil has changed progressive decrease of age from 66 to 63 years MEN WOMEN Regular smokers Obesity 75 y Men y < 60 y Women FAST- MI 2012

22 But incidence (STEMI) not decrease increase? Mortality Incidence MONICA Wagner A et al Bull Epidemiol Hebdo 2006; n 8-9:65-66

23 if we want to decrease CAD incidence we should rehabilite our patients Studies prove it

24 FAST MI Results: secondary prevention treatment at 1 year Individual classes at 1 year Co

25 Effect of endurance training on vascular risk factors, hemodynamic, and hormones Meta-analysis 72 studies Patients with and without hypertension Exercise 4 weeks Vascular resistance plasmatic Renin activity Norepinephrin Weight Waist circumference insulin resistance Lipids HDL Blood pressure 7.1 % 20% 29% 1.2 kg 2.8 cm 0.31 U 1.4% / 4.9 HTA 1.9 / 1.6 P < Véronique A et al., Hypertension, 2005

26 6 meta-analyses since randomized clinicals trials ( n: Pts) - 20 % significant positive changes in modifiable risk factors (total cholesterol, triglycerides and systolic blood pressure) - 25 % Oldridge N. Future Cardiol 2012;8:729-51

27 Participation in Cardiac Rehabilitation, Readmissions, and Death After Acute Myocardial Infarction 2991 STEMI ( ) 52% patients rehabilitation Ré hospitalisation : -25% Dunlay S Am J Med (2014) 127,

28 47 studies randomising 10,794 patients Overall mortality : 13 % Cardiovascular mortality : 26% Not reduce the risk of total MI, CAGB or PTCA Hospital admissions : - 31% ( < 12 mois) 10 trials reporting health-related quality of life Heran et al: Cochrane database sys.review 2011 Jul 6;(7):CD001800

29 Cost (SEK) of post MI rehabilitation vs Control group Intervention group N = 147 Control group N = 158 Difference Physical training program Rehospitalisation Clinical follow-up By pass surgery drugs Cost of training Cost of medical visit Direct total cost time of training cost time of visits cost Lost of production (work stoppage) Total cost LEVIN LA, et al J Int Med 1999 ; 230 : 427

30 Physical training increase the coronary flow reserve ( FFR - CFR)

31 PET (101 patients) Comparison angioplasty versus Physical training Results at 1 year 80% 75% 70% 65% Scintigraphie myoc initiale at 0 Scintigraphie myoc at à mois months 60% 55% Entrainement Réhabilitation Angioplastie PCI Myocardial perfusion during demake-up exercise myocardial scintigraphy in CAD patients. Same decrease of LV perfusion defect in both groups HAMBRECHT R, Circulation 2004; 109:

32 Endothelial Activation Growth factors Physical exercice Hypoxia + pressure gradient Endothelial activation and growth factors Neo angiogenesis and arteriogenesis (Collateral Circulation)

33 Endothelial Cells: Nitric oxyde (NO) Ca 2+ L-Arginine NO-Synthase O 2 Citrulline Relaxation Cellule Endothéliale Hyperpolarisation NO Ca 2+ K + GMPc Guanylate Cyclase GTP Réticulum Sarcoplasmique Cellule Musculaire Lisse

34 Non-invasive Visualisation of the LAD by color flow Doppler by transthoracic echocardiography

35 Non-invasive CFR by transthoracic Doppler echocardiography CRF : 2,9 Concordant High CFR and FFR

36 Non-invasive CFR by transthoracic Doppler echocardiography CRF : 1,6 Concordant Low CFR and FFR

37 Correlation between invasive FFR and non-invasive CFR

38 Correlation between non-invasive CFR and exercise capacity

39 Pronostic value of exercise capacity with or without history of CV events Each 1 MET is associated with of 13% of mortality 6749 blacks 8911 whites KOKKINOS P., MYERSJ. Circulation 2008;117:

40 Cardiac réhabilitation Decreases morbi-mortality Improves vascular risk factors profil Improves physical workload, activity Improves quality of life Decreases cost management of CAD Is cardiac rehabilitation necessary? YES

41 Conclusion Recent guidelines in the UK and USA have concluded with the recommendation that cardiac rehabilitation is reasonable and necessary and should be promoted by healthcare professionals, including senior medical staff Oldridge N. Future Cardiol 2012;8:729-51

42 THANK YOU FOR YOUR ATTENTION THE FUTURE DRUGS, PREVENTION, and READAPTATION Will replace ANGIOPLASTY PERCUTANEOUS ANGIOPLASTY Will replace SURGERY