EUROASPIRE III ROMANIA THE NEED TO REINFORCE CARDIAC REHABILITATION IN PATIENTS WITH CORONARY ARTERY DISEASE

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1 ORIGINAL ARTICLES EUROASPIRE III ROMANIA THE NEED TO REINFORCE CARDIAC REHABILITATION IN PATIENTS WITH CORONARY ARTERY DISEASE Adina Avram, Stela Iurciuc, Laura Craciun, Claudiu Avram, Mircea Iurciuc, Cristian Sarau, Gabrijela Gojka, Anca Grosos, Simina Urseanu, Daniel Duda- Seiman, Maria Rada, Dan Gaita, Silvia Mancas REZUMAT Scopul studiului: Investigarea practicii clinice în domeniul recuperării cardiovasculare în ţara noastră prin analiza lotului de 566 pacienţi coronarieni incluşi în studiul multicentric european EuroAspire III România. Material şi metodă: Criteriile de includere şi designul studiului au urmat protocolul EuroAspire. Pentru evaluarea pacienţilor am folosit metoda chestionarului, am măsurat parametrii antropometrici şi hemodinamici şi am recoltat analize de sânge. Am evaluat profilul cardiometabolic în funcţie de asocierea factorilor de risc cardiovascular (FRcv) tradiţionali şi controlul acestora. Rezultate: Au fost înrolaţi 566 de coronarieni. S-a recomandat includerea într-un program de recuperare unui număr de 139 de pacienţi (24%). 81 de pacienţi (14%) au participat la recuperare, majoritatea fiind bărbaţi din mediul urban, pensionari la limita de vârstă, supuşi unei intervenţii de revascularizare chirurgicală 48% sau intervenţională - 49%, care prezentau asociat FRcv în proporţii variabile. Analiza efectuată iniţial şi la un interval de 16 luni de la intervenţia de revascularizare a decelat o ameliorare a valorilor medii ale FRcv în rândul pacienţilor incluşi într-un program de recuperare. Ţintele terapeutice recomandate de ghid au fost atinse într-o proporţie scăzută: 57% atingeau ținta pentru colesterol total, 58% pentru LDL colesterol şi doar 43% pentru tensiune arterială. Concluzii: Studiul a evidenţiat o participare redusă a pacienților coronarieni în programele de recuperare cardiovasculară, deşi rolul benefic al recuperării este astăzi unanim recunoscut. Trebuie să identificăm cauzele care limitează accesul pacienţilor coronarieni, fie că ţin de medic, pacient sau de alţi factori externi şi să acționăm corectiv asupra lor, în scopul creşterii standardului îngrijirii medicale. Cuvinte cheie: recuperare cardiovasculară, boala coronariană, factori de risc cardiovascular ABSTRACT Aims: To investigate the current practice regarding cardiac rehabilitation in the west region of our country, analyzing the 566 Romanian coronary patients included in EuroAspire III, a multicentric European Survey. Material and methods: Inclusion criteria and study design followed the EuroAspire III survey protocol. We evaluated life style trends and cardiovascular risk factors management using questionnaire method, measuring anthropometric and hemodinamic parameters and performing blood tests. Results: We enrolled in the survey 566 coronary patients, 24% of them reported being advised to attend cardiac rehabilitation programs and 14% participated in a comprehensive CR. Patients who participated in cardiac rehabilitation were mainly men, from urban area, aged-related retired, associating various risk factors, who underwent myocardial revascularization surgery - 48%, or interventional procedures - 49%. After a mean period of follow-up of 16 months, we noticed an improvement in the mean values of some of the risk factors, though targets were achieved in 57% patients for total cholesterol, 58% for LDL cholesterol and only in 43% for blood pressure. Conclusions: We noticed a reduced participation of coronary patients in CR, even though the CR benefits are worldwide recognised. We need to identify the existing bariers for CR participation, related to physicians, patients or other external factors and to find solutions to overcome them, in order to rise the standard of current practice. Key Words: cardiac rehabilitation, coronary patients, cardiovascular risk factors INTRODUCTION Department of Preventive Cardiology and Cardiovascular Rehabilitation, Institute of Cardiovascular Diseases, Timisoara Correspondence to: Dr. Adina Avram, 1 Baba Dochia Str., Timisoara, Tel pc_adina@yahoo.com Received for publication: Jul. 11, Revised: Nov. 23, The benefit of comprehensive cardiac rehabilitation (CR) programs in patients with coronary heart diseases had been demonstrated in numerous clinical studies. 1,2 Traditional candidates for CR were patients with recent myocardial infarction or those who had undergone coronary artery bypass graft surgery. 3,4 Current recommendations enlarged the inclusion criteria in Adina Avram et al 299

2 CR programs, from patients who have undergone percutaneous coronary interventions, patients with stable angina pectoris; patients with stable chronic heart failure, peripheral arterial disease with claudication, to all patients who have undergone other cardiac surgical procedures (heart transplantation candidates or recipients, heart valve repair or replacement). 5,6 In spite of present evidences, the participation of coronary patients in CR is still reduced. 7 EuroAspire survey, the most important European study on cardiovascular prevention and rehabilitation, organized under the auspices of European Society of Cardiology, offers a clear picture regarding rehabilitation practice over different European countries. EuroAspire I and II surveys both showed a high prevalence of unhealthy lifestyles, modifiable risk factors and inadequate use of drug therapies to reach risk factors goals in patients with established coronary heart disease (CHD). 8 In Romania participated for the first time in the two arms of EuroAspire survey: Hospital Arm, which took part within Institute of Cardiovascular Diseases Timisoara and investigated patients with established CHD and Primary Care Arm, which enrolled asymptomatic patients at high risk for cardiovascular diseases from 6 family doctors praxis from Timisoara. Timisoara was the only center in Romania that participated in EuroAspire survey. OBJECTIVES The present study aims to investigate the current clinical practice regarding cardiac rehabilitation in our country, analyzing the patients with CHD enrolled in the Hospital Arm of EuroAspire III Romania, the single center from our country. We wanted to find out to what extent physicians refer to rehabilitation patients following cardiac events (revascularization procedures, acute myocardial infarction and acute ischemia without revascularization procedure); which are the participation rates and general profile of patients who participated in CR programs offered by Cardiovascular Rehabilitation Clinic in Timisoara; what are their main outcomes in regard to risk factors control after a mean period of 16 months following the cardiac event. MATERIAL AND METHODS Inclusion criteria Men or women (< 80 years), with first or recurrent clinical diagnosis or treatments for CHD (elective or emergency coronary artery by-pass graft (CABG), percutaneous transluminal coronary angioplasty 300 TMJ 2010, Vol. 60, No.4 (PTCA), acute myocardial infarction, acute myocardial ischemia but no evidence of infarction, retrospectively identified from diagnostic registers, hospital discharge lists or other sources. The starting date for identification was not less than 6 months prior to the expected date of interview and not more than 3 years. Study design Selected patients received an invitation letters from organizers. According to study protocol, they were invited to fill in the validated study questionnaire, underwent a minimal clinical examination and blood had been drowned for biologic tests. The questionnaire consisted in 41 questions regarding life style measures and medication. We measured: height, weight, waist circumference, blood pressure, heart rate, using the equipments stipulated in the protocol (SECA measuring stick model 220, SECA scale model 701, Omron M5-I automatic digital sphygmomanometer). The lab tests performed were: fasting glucose, serum total cholesterol, high-density lipoprotein (HDL) cholesterol, triglycerides, low-density lipoprotein (LDL) cholesterol. The units were expresed in mg/ dl. Biological evaluation technic were according to the current standards. We set general characteristics for the survey participants according to their age, gender, inclusion criteria, participation in CR according to physicians recommendations. Based on their participation in rehabilitation, we split the whole lot into 3 groups: Group 1, patients who were referred to and who participated in CR; Group 2, patients who were referred to rehabilitation to but did not participated in CR; Group 3, patients who were not referred to and consequently did not participated in CR. We characterized the 3 groups according to gender, inclusion criteria, personal and demographic data, cardiovascular risk factors association. We defined risk factors as unmodifiable risk factors: men > 55 years old and women >65 years old, and modifiable risk factors: hypertension - personal history of hypertension and antihypertensive drug therapy or blood pressure >140/90 mmhg, respectively >130/80 mmhg in diabetics; hypercholesterolemia - personal history of hypercholesterolemia and lipid-lowering drug therapy or serum total cholesterol>175 mg/ dl), diabetes mellitus personal history and diabetes therapies (diet and/or oral antidiabetic drugs), obesity body mass index (BMI) > 30 kg/m2; smoking persons who smoked more than 1 cigarette/day in the last 6 months. In order to investigate cardio metabolic profile of patients who participated in rehabilitation, we calculated the mean values for systolic and diastolic

3 blood pressure, serum total cholesterol, body mass index (BMI), fasting glucose, both at baseline (T1) and after a mean period of 16 months (T2). We calculated the percentage of patients reaching the targets set in 2007 European Guidelines of Cardiovascular Prevention. These targets are: blood pressure < 140/90 mmhg, respectively < 130/80 mmhg in diabetics, total cholesterol < 175 mg/dl, LDL cholesterol < 100 mg/dl, HDL cholesterol > 45 mg/dl, triglycerides <150 mg/dl, BMI < 25 kg/m2.9 Statistic analysis: the following variables were expressed as mean value + standard deviation; we calculated percentages from group; subgroup comparison were validated using Student test t (p<0.05 was considered statistically significant). Statistic analysis was performed with the help of the statistic program Epi Info 6 (version 6.04d). RESULTS General characteristics of survey participants at baseline In EuroAspire III Romania, Hospital Arm we enrolled 566 coronary patients, mean age ± 9.80 years old, with CABG - 27%, or PTCA - 59%, or acute myocardial infarction - 6% or acute myocardial ischemia without infarction - 8%. Cardiologists referred to rehabilitation 139 patients (24%), the rest of 427 patients (76%) reported they were not advised to participate in CR. A number of 81 patients (14%) participated in a CR program, and the rest of 57 patients (10%) did not attend any CR, even though they were referred by cardiologists. (Fig. 1) Figure1. Recommendation and participation rates in cardiac rehabilitation in EuroAspire III Romania, Hospital Arm: Group 1- recommendation (+), participation (+); Group 2 - recommendation (+), participation (-); Group 3 - recommendation (-), participation (-). General profile of patients included in CR at baseline The rehabilitation group, Group 1, consisted of 81 participants, mean age ± 9.87 years, 75% men, 25% women; meeting the following diagnostic criteria: CABG - 48%, PTCA - 49%, acute myocardial infarction - 1% and acute myocardial ischemia without infarction - 2%. Three quarters of the patients lived in an urban area and 48 patients (59%) were retired: 34 aged related, 9 CHD related, 2 other illness related, 3 personal choice. Regarding unmodifiable risk factors, 47 men were > 55 years old and 9 women were >65 years old. Modifiable risk factors were also identified: 68% had hypertension, 53% had hypercholesterolemia, diabetes mellitus type 2 was noticed in 20% of patients, 38% were obese, 59% were former-smokers and 5% active smokers at baseline. Cardio metabolic profile of patients included in CR at baseline and after 16 months Mean values of hemodinamic (systolic and diastolic blood pressure) and metabolic parameters (total cholesterol, BMI, fasting glucose) in Group 1 at baseline (T1) and at the end of the study (T2) are listed in Table 1. Mean values decreased at 16 months for diastolic blood pressure from 82.16±12.25 to 80.55±12.91, (p=0.41); total cholesterol from ±51.09 to ±48.51, (p=0.01); BMI from 32.70± to 28.86±14.71, (p= 0.21) and fasting glucose from ±39.51 to ± 45.9, (p=0.35). Only total cholesterol reduction was statistically significant. Table 1. Mean values of cardio-metabolic parameters in rehabilitation group at baseline (T1) and after 16 months (T2). Variables T1 T2 p SBP (mmhg) ± ± DBP (mmhg) 82.16± ± TC (mg/dl) ± ± LDL (mg/dl) 109.2± ± HDL (mg/dl) 41.83± ± TG (mg/dl) 211.2± ±92.06 <0.01 BMI (kg/m 2 ) ± ± Fasting glucose (mg/dl) ± ± SBP: systolic blood pressure; DBP: diastolic blood pressure, TC: total cholesterol; LDL: low density cholesterol; HDL: high density cholesterol; TG: triglyceride; BMI: body mass index. Risk Factor control in patients included in CR after 16 months Risk factors control was suboptimal: more than a half of the patients reached the recommended targets for total cholesterol, LDL-cholesterol and triglycerides, but only 43% reached guideline targets for blood pressure. Only one quarter of patients reached target for fasting glucoses and even less, almost one fifth of patients had BMI lower than 25 kg/m 2. Adina Avram et al 301

4 Table 2. General characteristics in the 3 groups at baseline (T1). Group 1 Group 2 Group 3 Sex Male (%) Women (%) Inclusion criteria CABG (%) PTCA (%) Acute miocardial infarction (%) Acute ischaemia without infarction (%) Personal and demographic data Urban Rural Retired age related (%) Retired heart disease related (%) Retired other illness related (%) Retired personal choice (%) Unmodifiable risk factors Men > 55 years old (%) Women > 65 years old (%) Modifiable risk factors Hypertension (%) Hypercholestrolemia (%) Diabetes mellitus type 2 (%) Obesity (%) Active smoker (%) Figure 3. Percentage of patients in Group 1 reaching ESC targets after 16 months for the modifiable risk factors: blood pressure (BP), fasting glucose (Fstg. Gluc.), body mass index (BMI), total cholesterol (TC), LDL cholesterol (LDL), HDL cholesterol (HDL), triglycerides (TG). DISCUSSION Figure 2. Mean values of total cholesterol (CT) and triglycerides (TG) in the Group 1 at baseline (T1) and after 16 months (T2). 302 TMJ 2010, Vol. 60, No.4 Over the past 40 years, the role of CR in the continuum of care for persons with cardiovascular disease was recognized as significant. 10 CR is now regarded as comprehensive, long-term programs, containing specific core components, such as medical evaluation, individualized exercise training, cardiac risk-factors modification, education and counseling, that aim to optimize cardiovascular risk control, implement healthy behaviors and life-long compliance to these behaviors, reduce disability, improve function,

5 decrease morbidity and mortality and enhance the patient s quality of life. 11,12 Despite the documented evidence of the benefits of cardiac rehabilitation in patients with CHD, worldwide evidence suggests that referral to and subsequent participation in CR remains low. 13 EuroAspire surveys I, II and III give us a dynamic picture regarding referral to and participation in CR participation in Europe. EuroAspire II enrolled 5540 consecutive coronary patients from 47 centres in 15 countries at about 1.4 years after hospital discharge for an acute cardiac event. 43% reported being advised to attend a CR and of these 81.8% did so; 35.2% of all patients. 8 Only one third of European patients from the 22 countries participating in EuroAspire III accessed any form of cardiac rehabilitation. The highest rates of CR utilization were noticed in Lituania, were 90.3% were referred and 85.4% of the patients participated in CR, in Ireland 88% of patients were referred and 67.4% participated in CR and in Belgium: 77.8% were referred and 60.2% participated in CR. The lowest values were noticed in Russia: indication for CR was 8.2% and participation 2.7%; Turkey: indication for CR was 7.3%, participation 2.1%; Greece: indication for CR was 0.8%, participation 0% and Spain: indication for CR was 0.8% and participation 0.2%. 14 A recent study conducted by Brown T. et al in USA in 2009, analyzed 72,817 eligible CHD patients discharged alive between January 2000 and September 2007 from 156 hospitals showed that only 56% of patients were referred to cardiac rehabilitation ranging from 53% for myocardial infarction to 58% for PTCA and to 74% for CABG patients. 15 Research conducted identified barriers to both participation and adherence to CR. Among factors independently associated with participation in CR programs, we would mention: lack of referral by physicians, associated illness, specific cardiac diagnoses, reimbursement, distance and transportation, selfconcept, self-motivation, family composition, social support, self-esteem, and occupation. 16 Barriers to an optimal adherence to CR are mainly patient-related and they include: being older, female gender, having fewer years of formal education, perceiving the benefits of CR, having angina, and being less physically active during leisure time. 17,18 The physician s referral remains an important determinant for CR participation if the physician does not recommend cardiac rehabilitation then the patient is most unlikely to join such a program. A study conducted in Canada, which enrolled 3536 CABG patients automatically referred to CR at the time of hospital discharge, proved that institutionalized, physician-endorsed system of automatic referral to cardiac rehabilitation resulted in higher rates of participation and adherence to CR following CABG than those identified in other cardiac populations. 19 Even though automatic referral, using electronic health records or systematic discharge order sets, as mentioned above, proved to be efficient in increasing CR utilization, the highest rates of CR adherence have resulted from a combination of automatic and liaison (discussions with allied health-care providers) methods. 20 Other factor that was proved to influence CR referral in the type of medical provider, with cardiologists more likely to refer than primary care physicians. 21 On national level, data regarding CHD patients participation and adherence in CR are rather poor. 22 Romanian participation for the first time in EuroAspire program within Institute of Cardiovascular Diseases from Timisoara gave us a good opportunity to obtain a realistic picture regarding CR clinical practice in our region. Only one quarter of Romanian patients enrolled in EuroAspire III were advised to follow CR, comparing to 56.6% of the patients in Hungary, or 71.3% of the patients from Bulgaria. Regarding participation in CR, the rates registered in Romania were comparable with those from Bulgaria, where only 15% of the patients were enrolled, and much reduced comparing with Hungary, where half of the patients participated in CR. In France, or in United Kingdom, enrollment in CR was almost double comparing with our country 27% in France, respectively 28% in United Kingdom.11 Due to the fact that Timisoara is the only center in Romania with a dedicated prevention & rehabilitation department within a institute of cardiovascular diseases, we can only presume that our results might be more favorable than those obtained in other centers with tradition in the field of CR. CONCLUSIONS Our study showed a reduced participation of coronary patients in CR programs, even though rehabilitation benfits are now worldwide recognised. We found that participation in rehabilitation improved long-term risk factors controll, mainly in regard to lipids. Our results show that there is a strong need to identify the bariers in regard to the participation of coronary patients in CR and to find innovative solutions to overcome these barriers, in order to improve the quality of care in patients with CHD. Adina Avram et al 303

6 REFERENCES 1. Jolliffe JA, Rees K, Taylor RS, et al. Exercise-based rehabilitation for coronary heart disease. Cochraine Database Syst Rev 2001;(l):CD Taylor RS, Brown A, Ebrahim S, et al. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and metaanalysis of randomized trials. Am J Med 2004;116: Zdrenghea D, Gaita D, Pop D. Recuperarea moderna a cardiopatiei ischemice. În Capâlneanu R (ed): Progrese în cardiologie, volumul II. Media Med Publicis 2007, ; ISSN I Gaita D, Avram A, Avram C. Antrenamentul fizic in recuperarea cardiovasculara Editura Brumar, Timisoara, 2007 ISBN Leon A, Franklin B, Costa F, et al. Cardiac Rehabilitation and Secondary Prevention of Coronary Heart Disease. An American Heart Association Scientific Statement From the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in Collaboration With the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2005;111: Zdrenghea D. Recuperare si Preventie Cardiovasculara. Editura Clusium, Cluj-Napoca, 2008, ISBN Cottin Y, Cambou JP, Casillas JM, et al. Specific profile and referral bias of rehabilitated patients after an acute coronary syndrome. J Cardiopulm Rehabil 2005;25(2): Kotseva K, Wood DA, De Bacquer D, et al. Cardiac rehabilitation for coronary patients: lifestyle, risk factor and therapeutic management. Results from the EUROASPIRE II survey. Eur Heart J Supplements (2004) 6 (Suppl. J), J17 J Graham I, Atar D, Borch-Johnsen K, et al. European guidelines on cardiovascular disease prevention in clinical practice: fourth joint task force of the European Society of cardiology and other societies. Eur J Cardiovasc Prev Rehabil 2007;14(Suppl 2):S1-S Thomas R, King M, Lui K, et al. AACVPR/ACC/AHA 2007 Performance Measures on Cardiac Rehabilitation for Referral to and Delivery of Cardiac Rehabilitation/Secondary Prevention Services. J Am Coll Cardiol 2007;50: Mancas S, Dragan S, Gaita D, et al. The effects of phase II of cardiovascular rehabilitation on lipids and lipoproteins in diabetic patients with and without cardiovascular disease. European Journal of Cardiovascular Prevention & Rehabilitation 2004;11(Suppl.1): Piepoli M, Corra U, Benzer W, et al. Secondary prevention through cardiac rehabilitation from knowledge to implementation: a position paper from the cardiac rehabilitation section of the European association of cardiovascular prevention and rehabilitation. Eur J Cardio Prev Rehab Balady GJ, Williams MA, Ades PA. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation ;115(20): Kotseva K, Wood D, De Backer G, et al. EUROASPIRE III: A survey on the lifestyle, risk factors and use of cardio protective drug therapies in coronary patients from twenty-two European countries. Eur J Cardio Prev Rehab 2009;16: Brown T, Hernandez A, Bittner V, et al. Predictors of cardiac rehabilitation referral in coronary artery disease patients. Findings From the American Heart Association s Get With The Guidelines Program. J Am Coll Cardiol 2009;54: Daly J, Sindone A, Thompson D, et al. Barriers to participation in and adherence to cardiac rehabilitation programs: A Critical Literature Review. Prog Cardiovasc Nurs 2002;17(1): Fernandez R, Davidson P, Griffiths R. Cardiac rehabilitation coordinators perceptions of patient-related barriers to implementing cardiac evidence-based guidelines. J Cardiovasc Nursing 2008;23(5): Mitu F, Mitu M, Turiceanu M, et al. Particularităţi ale pacienţilor vârstnici cu infarct miocardic, Rev Med Chir Soc Med Nat Iasi. 2004;108(3): Smith K, Harkness K, Arthur H, et al. Predicting cardiac rehabilitation enrollment: the role of automatic physician referral. Eur J Cardio Prev Rehab 2006;13 (1): Gravely-Witte S, Leung Y, Nariani R, et al. Effects of cardiac rehabilitation referral strategies on referral and enrollment rates. Nature Reviews Cardiology 2010;7: Grace S,Grewal K, Stewart D, et al. Factors affecting cardiac rehabilitation referral by physician specialty. J Cardiopulm Rehabil 2008;28(4): Vanhees L, Avram A, Gaita D, et al. Cardiac Rehabilitation: Europe. In Perk J, Mathes P, Gohlke H, Monpere, Hellemans I, McGee H, Sellier P and Saner H (eds): Cardiovascular Prevention and Rehabilitation, Springer-Verlag, London, 2007, TMJ 2010, Vol. 60, No.4

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