HEART FAILURE AN OMINOUS DISEASE

Transcription

1 HEART FAILURE AN OMINOUS DISEASE

2 Conflicts of Interest I Have No Conflicts of Interest to Disclose

3 Objective At the conclusion of this presentation, the participants will be able to identify benefits and details of Cardiac Rehabilitation Program for heart failure patients

4 BREAKING NEWS The Centers for Medicare and Medicaid Services (CMS) has confirmed effective date for patients with heart failure(hf) to receive cardiac rehabilitation services is: February 18, 2014

5 Who is Eligible STABLE CHRONIC HEART FAILURE PATIENTS Pts. who have not had recent (<6 weeks) or planned (< 6 months) major cardiovascular hospitalizations or procedures. Left ventricular ejection fraction <35% New York Heart Association (NYHA) class II to IV symptoms (despite being on HF therapy for at least 6 wks) (HF is preferred over CHF because some pts. present without signs or symptoms of volume overload)

6 Why CMS Supported CR for HF CMS found little evidence in existing literature that supported CR for HF pts (O Connor) HF-ACTION Study (HF:A Controlled Trial Investigating Outcomes of Exercise Training) a. Largest single trial (n=2331)- most well designed and provided best evidence of benefit

7 HF-ACTION STUDY- April 2003 to February 2007 Randomly assigned a. Exercise training (60-70% HRR) b. Usual Care (no formal exercise prescription-exercise was simply encouraged)

8 HF-ACTION STUDY (published in 2009) Age range (Median age of 59) 72% men LVEF < 35% (Mean 25%) Follow-up ( goal of a minimum of 1 yr. and maximum of 4 yrs. - median 30.1 months)

9 HF-ACTION STUDY Exercise Training Group a. Structured, group based, and supervised exercise b. 3 sessions/week for a total of 36 sessions in 3 months c. Followed by home based 5x/week for 40 min. exercise on a treadmill or stationary bicycle

10 HF-ACTION STUDY All Patients Received Educational Materials a. Medications b. Fluid Management c. Symptom Exacerbation d. Sodium Intake e. Activity Level of 30 min (as tolerated)

11 HF-ACTION STUDY RESULTS 11% reduction in the adjusted risk for the combined endpoint of all-cause mortality or hospitalization Quality of life and mental depression also improved

12 COURSE of ACTION One of the most propitious course of action in helping HF patients deal with their complications is.

13 Cardiac Rehabilitation 36 sessions- for most insurances 3 x/week- highly encouraged min of aerobic exercise and weight training if tolerable Monitor HR, O2, BP and RPE Progress according to patients tolerance

14 COMPONENTS OF CARDIAC REHAB Education Nutrition and Heart Disease Dining In/Dining Out Making Sense of Food Labels Achieving a Healthy Weight Heart Talk: How it Works and More Stress and Heart Disease Relaxation Managing Risk Factors Cardiac Meds- Part 1 and 2 Heart Stories The Science of Exercise Tools for Empowering Your Healing Process

15 Aerobic Benefits of CR for HF Patients Lower response to submaximal exercise Improves diastolic function Improved endothelial function Increased skeletal muscle oxidative capacity Enhanced vagal tone and lower sympathetic tone Has anti-inflammatory and anti-oxidative effects Lower all-cause mortality or hospitalization Improved quality of life Reduced peripheral vasoconstriction Decreases circulating catecholamine levels Affects left ventricular remodeling

16 COMPONENTS OF CARDIAC REHAB Aerobic Exercise Low-intensity, longer duration workout are preferred over high-intensity activities Start with shorter sessions and gradually build up Take frequent breaks Include warm-up and cool-down Watch for fatigue and SOB

17 Benefits of Strength Training in CR for HF Patients Dynamic resistive training has anti-inflammatory effects Improves insulin resistance Counteract loss of skeletal mass and strength Increases muscle strength and endurance Improves QOL

18 Best Practice in Weight Training Training in a dynamic way Avoid valsalva maneuvers Keep training at low to moderate intensity- high repetition and low resistance Sustained maximal isometric exercise is contraindicated because of excessive rise in BP and lowering of SV

19 Program Statistics for CHF Patients From January, 2017 thru July, 2017 Total patients enrolled= 268 Total CHF patients= 78 (38%) Average EF= 36% Average EF for non CHF= 54% Average MET level starting for CHF patients= 4.85 Finishing program= 6.59 Average MET level starting for non CHF patients= 4.9 Finishing program= 7.18

20 GOALS FOR CR Control symptoms Improve QOL Prevent hospitalization Prevent mortality Provide patient education

21 OUR CHALLENGE As exercise specialists, we need to break down possible existing barriers and fears related to exercising patients with HF and use our knowledge in delivering effective health interventions so that both efficiency and safety are guaranteed.

22 POSTER PATIENT Current Age= CABG (36 yrs old) CABG (43 yrs. old) MI (54 yrs old) CABG (58 yrs old) Pacemaker (71 yrs. old) ICD (77 yrs. old) Angioplasty (80 yrs. old) Current- CHF and EF= 30-35% 1990-Cardiac Rehab- at New Heart 2016 Cardiac Rehab- Presbyterian Healthplex Current Member in Cardiac Maintenace Program Presbyterian Healthplex