Cardiac rehabilitation: a beneficial effect in CHD?

Transcription

1 Cardiac rehabilitation: a beneficial effect in CHD? An Van Berendoncks Department of Cardiology Antwerp University Hospital

2 Outline Why exercise training in CHD? Risk and benefits? Feasibility?

3 Why should we consider exercise training in adults with CHD?

4 Reduced exercise capacity in ACHD Maximal oxygen uptake for a variety of CHD Thaulow E et al Int J Cardiol 2004

5 Reduced exercise capacity across spectrum of ACHD 80 % CHD patients had reduced peak VO2 Kempny et al Eur Heart J 2012

6 Impact on prognosis VO2 peak > 27 ml/kg/min VO2 peak ml/kg/min VO2 peak < 15.5 ml/kg/min Diller GD et al Circulation. 2005;112:

7 VO2 peak (ml/kg/min) Kempny et al Eur Heart J 2012; 33:1386 QoL improving exercise capacity is worthwhile in all ACHD patients home activities transport sport Occupation

8 Similar decrease in VO2 as heart failure patients Diller GD et al Circulation. 2005;112:

9 Correlates of Peak V O2 on Multivariable Regression Analysis r 95% CI P R2, % %FEV <0.001 NYHA class <0.001 Pulmonary arterial hypertension % of the variance in peak V O2 remained unexplained. BMI Cyanosis Gender Diller GD et al Circulation. 2005;112:

10 Unraveling new mechanisms of exercise intolerance in chronic heart failure. Role of exercise training Conraads V et al Heart Failure Rev 2013

11 Mechanisms of exercise intolerance in patients with adult congenital heart disease (CHD). Karen K. Stout et al. Circulation. 2016;133: Copyright American Heart Association, Inc. All rights reserved.

12 American Heart Association/American College of Cardiology congestive heart failure stages. Karen K. Stout et al. Circulation. 2016;133: Copyright American Heart Association, Inc. All rights reserved.

13 Beyond cardiac function Sedentary life style Low self esteem Regular exercise at recommended levels can be performed and should be encouraged in all patients with ACD Anxiety Societal bias against participation in exercise Inadequate exercise advice from professionals Eur J Cardiovasc Prev Rehabil 2006; 13:293

14 Goals to achieve with cardiac rehabilitation Improve exercise capacity VO2 peak Maximal workload Sub maximal exercise capacity Improve muscle function Improve QoL General health promotion (BMI, coronary risk factors, metabolic control, )

15 Risk and benefits?

16 General risk of rehabilitation sessions Cumulative incidence of death by the number of rehabilitation sessions attended patients cardiac rehab 1/1/2000 and 31/12/2012 Bradley G. Hammill et al. Circulation. 2010;121:63-70 Gene Kwan et al. circulation 2012; 125:

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18 Long term beneficial effect Van der Bom T Int J Cardiol 2015; 179;105

19 Tutarel Curr Cardiol Rep 2013

20 Diller & Baumgartner Eur Heart J 2016

21 Feasibility? / In practice

22 Individualized exercise prescription Budts W Eur Heart J. 2013;34(47):

23 Assessment before exercise training Can J Cardiol 2016

24 Basic factors of physical fitness Endurance capacity Strength (skeletal muscles - respiratory muscles) Coordination Speed of motion Body composition (fat mass - fat free mass)

25 CPET ET for assessing the impact of exercise on ACHD before advising any level of training in the clinical setting Graham et al J AM Coll Cardiol 2005; 45:

26 Type of training Paul Beckers, coordinator Cardiac Rehabilitation, Antwerp University Hospital

27 Not only endurance matters Type of exercise The need for more than increase in peak VO 2 In daily life patients are not concerned about peak performance Additional training types are necessary Paul Beckers, coordinator Cardiac Rehabilitation, Antwerp University Hospital

28 Combined endurance resistance training Beckers P Eur Heart J 2008; 29

29 Combined endurance resistance training Beckers P Eur Heart J 2008; 29

30 Case 1 16y old congenital PS postop pulmonary homograft Start First evaluation End VO2 (ml/kg/min) 37,9 (93% predicted) Maximal workload (watt) 180 (60% predicted) 48,5 (119% predicted) 220 (74% predicted) 56,7 (139% predicted) 260 (87% predicted) muscle strength upper limbs Increase 107% muscle strength lower limbs Increase 82% weight / fat free mass 66kg / 55 kg 69,5kg / 4,4 kg

31 Case 2 59y old TOF end stage heart failure Start First evaluation End VO2 (ml/kg/min) 13,1 (52% predicted) Maximal workload (watt) 60 (60% predicted) 17,1 (% predicted) 90 (90% predicted) 17,7 (70% predicted) 120 (120% predicted) muscle strength upper limbs muscle strength lower limbs 42, weight / fat free mass 53kg / 37,4 kg 56kg / 39 kg

32 Home exercise training Home-based walking 5/7 days for 10 weeks simple physical intervention like regular walking is simple, safe and significantly increases exercise capacity of adult patients of all stages of CHD Dua J et al Int J Cardiol 2010 Home Exercise Training in Children and Adolescents with Pulmonary Arterial Hypertension: A Pilot Study. Zoller D et al Pediatr Cardiol 2017

33 mhealth? Schuuring et al Neth Heart J 2016

34 Conclusions Majority of adults with CHD would benefit from exercise training ET improves prognosis, QoL and general health Risk < Benefit ratio Individual training prescription Structured cardiac rehabilitation vs home exercise training Encourage to continu aerobic exercise training at home