Qui dois-je adresser en réadaptation cardiaque? Who must I refer in cardiac rehabilitation?

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1 Atelier pratique How to session Qui dois-je adresser en réadaptation cardiaque? Who must I refer in cardiac rehabilitation? Un patient coronarien A patient with coronary artery disease Jeudi 14 janvier 2016 G. Bosser (Vandoeuvre les Nancy, FRANCE)

2 Déclaration de Relations Professionnelles Disclosure Statement of Financial Interest Aucune None

3 Should I refer my patient with coronary artery disease to cardiac rehabilitation?

4 Should I refer my patient with coronary artery disease to cardiac rehabilitation? YES!

5 RECOMMANDATIONS du (GERS) de La SFC Pratique De La Réadaptation Cardiovasculaire Chez L adulte Pavy B, Iliou MC, Vergès B, Brion R, Monpère C et al.

6 Maladie Coronaire Indications «classiques» Classe Niveau SCA «stabilisé» I A Pontages aorto-coronaires I B

7 Maladie Coronaire Indications «classiques» Classe Niveau SCA «stabilisé» I A Pontages aorto-coronaires I B Autres indications Classe Niveau Après ATL programmée I B Angor stable I B Haut risque CV I A

8 Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K et al. Am J Med. 2004;116(10): Included 48 trials with a total of 8940 patients

9 Compared with usual care, cardiac rehabilitation was associated with reduced All-cause mortality (odds ratio [OR] = 0.80; 95% confidence interval [CI]: 0.68 to 0.93) Cardiac mortality (OR = 0.74; 95% CI: 0.61 to 0.96)

10 Exercise-Based Cardiac Rehabilitation for Coronary Heart Disease. Cochrane Systematic Review and Meta-Analysis L Anderson, N Oldridge, DR Thompson, AD Zwisler, K Rees, N Martin, RS Taylor J Am Coll Cardiol 2016;67:1 12 A total of 63 studies with 14,486 participants with median follow-up of 12 months were included

86) Risk of hospital admissions (RR: 0.82; 95% confidence interval: 0.

11 Overall CR led to a reduction in Cardiovascular mortality (RR: 0.74; 95% confidence interval: 0.64 to 0.86) Risk of hospital admissions (RR: 0.82; 95% confidence interval: 0.70 to 0.96) There was no significant effect on total mortality, myocardial infarction, or revascularization

12 Cardiac rehabilitation and 5-year mortality after acute coronary syndromes: The 2005 French FAST-MI study. Pouche M, Ruidavets JB, Ferrières J, Iliou MC, Douard H, Lorgis L, Carrié D, Brunel P, Simon T, Bataille V, Danchin N. Arch Cardiovasc Dis Dec 17. Participants, from the 2005 French FAST-MI hospital registry, were 2894 survivors at discharge, divided according to AMI type: ST-segment elevation myocardial infarction (STEMI; n = 1523) and non- STEMI (NSTEMI; n = 1371) The effect of CR prescription on mortality was analysed using a Cox proportional hazards model At discharge, 22.1% of patients had a CR prescription. Patients referred to CR were younger (62.4 vs years), were more frequently men and more had presented with STEMI (67.8% vs. 48.3%) than non-referred patients

13 Ninety-four (14.7%) deaths occurred among patients referred to CR and 585 (25.9%) among non-referred patients (P < 0.001) After multivariable adjustment, the association between CR and mortality remained significant (hazard ratio [HR] 0.76, 95% confidence interval [CI] )

14 Association of diet, exercise, and smoking modification with risk of early cardiovascular events after acute coronary syndromes. Chow CK, Jolly S, Rao-Melacini P, Fox KA, Anand SS, Yusuf S. Circulation Feb 16;121(6): patients from 41 countries enrolled in the Organization to Assess Strategies in Acute Ischemic Syndromes (OASIS) 5 randomized clinical trial At the 30-day follow-up, patients reported adherence to diet, physical activity, and smoking cessation Cardiovascular events (myocardial infarction, stroke, cardiovascular death) and all-cause mortality were documented to 6 months About one third of smokers persisted in smoking. Adherence to neither diet nor exercise recommendations was reported by 28.5%, adherence to either diet or exercise by 41.6%, and adherence to both by 29.9%. In contrast, 96.1% of subjects reported antiplatelet use, 78.9% reported statin use, and 72.4% reported angiotensin-converting enzyme/angiotensin receptor blocker use.

15 6 months

16 Atherosclerosis prognosis I REACH registry (Coronary Artery Disease (CAD), Peripheral Arterial Disease (PAD), CerebroVascular Disease (CVD), 3 risks factors) n = Polyvascular disease PAD 60% CAD 25% CVD 40% Polyvascular Disease Poor outcome One-year cardiovascular event rates in outpatients with atherothrombosis. Steg PG et al ; REACH Registry Investigators. JAMA. 2007;297(11):

Atherosclerosis prognosis II Polyvascular disease and long-term cardiovascular outcomes in older patients with non-st-segment-elevation myocardial

17 Atherosclerosis prognosis II Polyvascular disease and long-term cardiovascular outcomes in older patients with non-st-segment-elevation myocardial infarction. Subherwal S et al. Circ Cardiovasc Qual Outcomes. 2012;5(4):541-9 Crusade non STEMI, 65 years PAD: ABI < 0.8 CVD: history of stroke

21 Drugs, Lifestyle modification, Exercise, No stent Or CABG Will reverse atherosclerosis Role of cardiac rehabilitation: motivation +++ Patient education Psychosocial dimension And optimal medical treatment And exercise

22 Cardiac rehabilitation Takes into account all the dimensions Of the disease Of f the patient Improve prognosis, with persistent Optimal treatment Healthy lifestyle Exercise Secondary prevention Primary prevention Same strategy Same disease

23 Exercise training coronary artery disease I International recommendations Moderately intense endurance aerobic exercise Moderately intense resistance exercise Cardiac rehabilitation Effects of exercise training Risk profile (lipids, glucose, weight, reduced hypertension) Anti-inflammatory effects Effects on blood clotting Autonomic functional changes Effects on vascular endothelial function Anti-ischemic effects Antiatherogenic effects Exercise standards for testing and training: a scientific statement from the American Heart Association. Fletcher GF et al. American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Nutrition, Physical Activity and Metabolism, Council on Cardiovascular and Stroke Nursing, and Council on Epidemiology and Prevention. Circulation. 2013;128(8): French Society of Cardiology guidelines for cardiac rehabilitation in adults. Pavy B et al; Exercise, Rehabilitation Sport Group (GERS); French Society of Cardiology. Arch Cardiovasc Dis. 2012;105(5):

24 Exercise training coronary artery disease II Improvement Quality of life Morbidity Mortality But only < 1/3 of coronary patient participate in cardiac rehabilitation in France! Exercise standards for testing and training: a scientific statement from the American Heart Association. Fletcher GF et al. American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee of the Council on Clinical Cardiology, Council on Nutrition, Physical Activity and Metabolism, Council on Cardiovascular and Stroke Nursing, and Council on Epidemiology and Prevention. Circulation. 2013;128(8): French Society of Cardiology guidelines for cardiac rehabilitation in adults. Pavy B et al; Exercise, Rehabilitation Sport Group (GERS); French Society of Cardiology. Arch Cardiovasc Dis. 2012;105(5):

25 Cardiovascular Effects of Exercise Training. Molecular Mechanisms Stephan Gielen, Gerhard Schuler, Volker Adams. Circulation. 2010;122:

26 Laminar shear stress N0

28 Angiogenesis

29 Effect of exercise training on vascular endothelial function in patients with stable coronary artery disease: a randomized controlled trial T-H Luk, Y-L Dai, C-W Siu, K-H Yiu, H-T Chan, S WL Lee et al. European Journal of Preventive Cardiology 2011;19(4): A randomized, controlled trial. Pts with stable CAD 8-week exercise training programme (3/Wk) (n=32) vs. controls (n=32) on brachial flow-mediated dilation (FMD) After 8 weeks, patients received exercise training had significant improvements in FMD (1.84%, p=0.002) and exercise capacity (2.04 metabolic equivalents, p<0.001) compared with controls.

30 Low exercise capacity Peak VO2<median Normal exercise capacity Peak VO2>median The change in FMD correlated inversely with baseline FMD (r=-0.41, p=0.001) and positively with the increase in exercise capacity (r=0.35, p=0.005) After adjusting for confounders, every 1 metabolic equivalent increase in exercise capacity was associated with 0.55% increase in FMD

31 Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial. Hambrecht R, Walther C, Möbius-Winkler S, Gielen S, Linke A, Conradi K et al. Circulation Mar 23;109(11): men with stable CAD Angina class I-III (Canadian Cardiovascular Society, CCS) Eligible; Monotruncular lesion, documented ischemia Randomization in two groups (same medical treatment) Percutaneous Coronary Intervention (PCI) with stent Exercise training; 20 min cycling/day/1year 1 year evaluation Combined clinical endpoint: death of cardiac cause, stroke, CABG, angioplasty, acute myocardial infarction, and worsening angina with objective evidence resulting in hospitalization VO 2

32 Exercise training 88% PCI stent 70% Exercise training was associated with a higher event-free survival (88% versus 70% in the PCI group, P0.023) Gain in VO 2 : 16 % vs 2 % Cost to gain 1 point in CCS score: 3429 vs 6986 $

33 Coronary collateral flow in response to endurance exercise training R Zbinden, S Zbinden, P Meier, D Hutter, M Billinger, A Wahl et al. Eur J Cardiovasc Prev Rehabil 2007, 14: Forty patients (age 61± 8 years) underwent a 3-month endurance exercise training program with baseline and follow-up assessments of coronary collateral flow Patients were divided into an exercise training group (n= 24) and a sedentary group (n= 16) according to the fact whether they adhered or not to the prescribed exercise program, and whether or not they showed increased endurance (VO2max in ml/min per kg) and performance (W/kg) during follow-up versus baseline bicycle spiroergometry Collateral flow index (no unit) was obtained using pressure sensor guidewires positioned in the coronary artery undergoing percutaneous coronary intervention and in a normal vessel In the vessel initially undergoing percutaneous coronary intervention, there was an increase in collateral flow index among exercising but not sedentary patients from 0.155± to 0.204± (P = 0.03) and from 0.189± to ± (NS), respectively In the normal vessel, collateral flow index changes were from 0.176± to 0.227± in the exercise group (P = ), and from 0.219± to ± in the sedentary group (NS)

34 A direct correlation existed between the change in collateral flow index from baseline to follow-up and the respective alteration of VO2max (P= 0.007) and Watt(P = 0.03).

35 Effect of exercise-based cardiac rehabilitation on non-culprit mild coronary plaques in the culprit coronary artery of patients with acute coronary syndrome. Kurose S, Iwasaka J, Tsutsumi H, Yamanaka Y, Shinno H, Fukushima Y et al. Heart Vessels Apr 21 Forty-one men with ACS, emergency PCI, 6-month follow-up, Divided into CR and non-cr groups Quantitative coronary angiography (QCA) was performed using the automatic edge detection program. The target lesion was a mild stenotic segment (10 50 % stenosis) at the distal site of the culprit lesion, and the segment to be analyzed was determined at a segment length ranging from 10 to 15 mm

36 The plaque area was significantly decreased in the CR group after 6 months, but was significantly increased in the non-cr group (P < 0.05) Peak VO2 in the CR group was significantly increased (P < 0.01) CR prevented the progression of mild coronary atherosclerosis in patients with ACS.

37 Should I refer my patient with coronary artery disease to cardiac rehabilitation?

38 Should I refer my patient with coronary artery disease to cardiac rehabilitation? YES!

39 Should I refer my patient with coronary artery disease to cardiac rehabilitation? All my patients? Even without ACS, CABG, angina, PCI? YES! They all have the same disease Atherosclerosis Same risk factors Same bad prognosis Give them a chance to be helped, accompanied Treatments improvements (guidelines) Healthy lifestyle Exercise Patient education, Psychosocial dimension Improvements Quality of life Morbidity (cost effectiveness) Mortality Because they are worth it!

Exercise after CABG: The Good The Bad and the Ugly

Exercise after CABG: The Good The Bad and the Ugly Ph Meurin. Les Grands Prés (Villeneuve Saint Denis) No conflict of Interest After CABG, the Prognosis is Good.. Age 65 ± 10 Male Gender 80 % Pre-op LVEF