Focus on Rehabilitation, Exercise and Surgical Coronary Revascularization

Transcription

1 Focus on Rehabilitation, Exercise and Surgical Coronary Revascularization

2 Sam Haddad, MD Kenneth O Reilly, MD

3 Disclosure of Commercial or Pharma Support NTD

4 Learning Objectives At the conclusion of this workshop, participants will be able to: Review the potential role of Surgical intervention Exercise and rehabilitation as heart failure management and treatment options

5 Surgical Coronary Revascularization

6 Case 1 69 year old male admitted with a diagnosis of HF Unwell x 3 months, progressive SOBOE and orthopnea Denies chest discomfort at any stage Past history HTN Diabetes diet only Former smoker Was treated medically after ACS 2 years ago Initial assessment: BP 120/92, HR 90 bpm (regular), obvious volume overload NT-BNP 4200 pg/ml, troponin I negative ECG: sinus rhythm, Q waves leads II,III, AVF, QRS duration 140 msec

7 Case 1 Echocardiogram performed: LVEF ~25%, global hypokinesis Mild MR RVSP ~ 45 mmhg Course in hospital over 7 days Diuresed 7 kg with IV furosemide, at dry weight Started on ramipril 5mg/d, and carvedilol 6.25 mg bid Ambulatory, wondering what we are going to do??

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9 Case 1 - What would you like to do next? A. Coronary angiogram B. Myocardial perfusion imaging (persantine sestamibi) C. Cardiac MRI D. Referral to EP for ICD and or CRT

10 Back to Case 1 Angiogram reveals multivessel coronary disease Occluded RCA 90% mid LAD lesion 70% OM1 and 90% OM2 lesions (medium size) Surgical colleague reviews the films: Technically graftable with good distal target vessels Serum creatinine stable at 140 mmol/l

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12 Case 1- Your recommended course of action? A. Discharge home with a plan for titrated medical therapy only until angina occurs B. Present the patient to CV surgical colleagues to consider surgical revascularization C. Refer to interventional colleague for multivessel PCI D. Referral for ICD/CRT

13 Prognostic significance of ischemic cardiomyopathy >1200 patients with invasive evaluation for cardiomyopathy over 15 years Ischemic etiology is also an independent predictor of mortality in risk models: Seattle Heart Failure Model (SHFM) Heart Failure Survival Score (HFSS) Levy et al, Circulation 2006 Aaronson et al, Circulation 1997 Felker et al, N Engl J Med 2000

14 Surgical Treatment for Ischemic Heart Failure where s the evidence? Individual patient level meta-analysis of 7 trials 2600 patients enrolled CABG associated with mortality reduction 39% at 5 years, 17% at 10 years No interaction with LV dysfunction and mortality reduction but higher absolute benefits seen in high risk subgroups Yusuf et al, Lancet 2004

15 Surgical Treatment for Ischemic Heart Failure where s the evidence? In these early studies: 90% had angina 80% had normal LVEF 10% had arterial conduits Medical therapy = digoxin and diuretics Need to assess the benefits of revascularization in contemporary patients with ischemic cardiomypathy Yusuf et al, Lancet 2004

16 Current Era: Surgical Treatment for Ischemic Heart failure (STICH) Randomized non-blinded study of surgical revascularization: Included patients with LVEF <35% and CAD suitable for revascularization Hypothesis 1: CABG + medical rx superior to medical rx alone Hypothesis 2: CABG + SVR superior to CABG alone in patients undergoing revascularization with anterior wall akinesis/dyskinesis Velazquez et al, J Thorac and Cardiovasc Surg

17 STICH Hypothesis 1: Primary outcome 1212 patients randomized to CABG vs medical therapy Patients with recent MI, major illness, significant L Main disease and severe angina excluded No difference in all cause mortality seen at median 56 months follow-up 17% of patients in medical therapy arm crossed over to surgical arm

18 STICH Hypothesis 1: secondary outcomes CABG associated with reduction in cardiovascular death and combined outcome of death or cardiovascular hospitalization CABG also associated with 30% relative reduction in mortality in on-treatment analysis (accounting for patients crossing over within 1 st year of study)

19 Recommendations - Revascularization Procedures Assessment for Coronary Disease We recommend that coronary angiography be: a)performed in patients with heart failure with ischemic symptoms, who are likely to be good candidates for revascularization. b)considered in patients with systolic heart failure (LVEF < 35%) at risk of coronary artery disease, irrespective of angina, who may be good candidates for revascularization. Strong Recommendation Moderate Quality Evidence Strong Recommendation Low Quality Evidence

20 Recommendations - Revascularization Procedures Surgical Revascularization for Patients with IHD and HF We recommend consideration of coronary artery bypass surgery for patients with chronic ischemic cardiomyopathy, LVEF < 35%, graftable coronary arteries and who are otherwise suitable candidates for surgery, irrespective of the presence of angina in order to improve quality of life, cardiovascular death and hospitalization. Strong Recommendation Moderate Quality Evidence

21 Recommendations - Revascularization Procedures Disease Management, Referral and Peri-operative Care We recommend that performance of coronary revascularization procedures in patients with chronic heart failure and reduced LV ejection fraction should be undertaken with a medicalsurgical team approach with experience and expertise in high risk interventions. Strong Recommendation Low Quality Evidence Values and Preferences: This recommendation reflects the panel preferences that high risk revascularization is likely to best occur in higher volume centres with significant experience, known outcomes, and similar to participating in clinical trials involving high-risk coronary revascularization. Practical Tip: Assessment for advanced heart failure therapies by an appropriate team should be performed prior to revascularization in any patient with advanced heart failure

22 Exercise Training and Heart Failure

23 Case A 74 year old man with ischemic cardiomyopathy LVEF 33% on echo, mildly dilated LV, MR 1/4 Treatments Candesartan 32mg od, bisoprolol 10 mg od, spironolactone 25 mg od, furosemide 20 mg od ICD for primary prevention since 2003 Stable NHYA II, also limited by bilateral hip pain (OA) Recent mibi shows no ischemia but an orthopedic surgeon refused to operate on his hips because of his cardiac condition

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25 Regarding exercise in this patient... A. He left ventricular ejection fraction is too poor to exercise B. He comorbidities are contra-indications to cardiac rehabilitation C. He should be referred for cardiac rehabilitation D. He should not exercise as he has a defibrillator E. He should be reassured and encouraged to purchase an elliptical trainer

26 Change in NYHA Class & Kansas City Cardiomyopathy Questionnaire (KCCQ) Score in HFACTION Study NYHA Class KCCQ Score p = 0.03 Percent of Patients Change in KCCQ total score at three months Improved Unchanged Worse Usual Care Exercise Training * P<0.001 compared to baseline O Connor CM et al, JAMA 2009 Flynn et al JAMA 2009

27 Potential Mechanisms by Which Exercise Training Improves Outcomes Organ System/Tissue Improve Central Transport and Regional Blood Flow Autonomic Nervous System Skeletal Muscle Peripheral vasculature Response to Exercise Training in cardiac output; in peak VO 2 ; reverse chronotropic incompetence; regional blood flow heart rate variability; plasma norepinephrine (rest) aerobic enzymes; mitochondria size/density; capillary density; relative type I fibers vasculature reactivity Effect on Mortality and Morbidity peak VO 2 survival; hospitalization HRV arrhythmia survival, hospitalization plasma NE survival muscle composition QOL hospitalization coronary blood flow Ischemia and MI survival, hospitalization

28 HF ACTION Study Design Chronic heart failure, NYHA Class II-IV, LVEF 35%, optimal HF medical therapy, capable of exercising Pre-randomization CPX and ECHO Randomization 1:1 (Stratified by center and HF etiology) Usual Care Whellan DJ. Am Heart J N = 2331 Median Follow-up 2.5 years Exercise Training Supervised exercise (36 sessions) 3d, 30 min 60-70% HRR Home exercise (months: 3-30) 5d, 40 min 60-70% HRR

29 All-Cause Mortality or All-Cause Hospitalization * Adjusted for prognostic factors: duration of CPX; LVEF; Beck Depression score; history A Fib or A Flutter; HF etiology O Connor CM et al, JAMA 2009

30 Recommendations - Rehabilitation and Exercise in HF Exercise Training in Patients with Heart Failure We recommend that all patients with stable New York Heart Association class I-III symptoms be considered for enrolment in a supervised tailored exercise training program, in order to improve exercise tolerance and quality of life. Strong Recommendation Moderate Quality Evidence Values and Preferences: This recommendation places a high value on improvements in non fatal outcomes and recognizes that not all patients will be able to participate in a structured exercise training program due to patient preferences or availability of resources.

31 Recommendations - Rehabilitation and Exercise in HF Exercise Training in Patients with Heart Failure We recommend that an assessment of clinical status by a clinician experienced in the management of heart failure patients be completed prior to considering an exercise training program. Strong Recommendation Low Quality Evidence Values and Preferences: This recommendation places a high value on clinician s assessment of both the clinical stability of a patient and their appropriateness to start exercise, recognizing that most patients will be eligible to participate.

32 How much exercise should you tell the patient to perform? A. Whatever they feel like because it really doesn t matter. B. Low intensity exercise so the heart is not stressed. C. Moderate-intensity continuous exercise (walking/swimming). D. 4. Should be involved only in strength/weight training.

33 Practical Tips Rehabilitation and Exercise in HF with an ICD Exercise Prescription and Exercise Modalities in HF 1. Exercise training is safe and not associated with an increased risk of ICD therapy. 2. The maximal target HR should be at least 20 beats below the ICD intervention heart rate to avoid inappropriate ICD shocks. 3. For patients with ICD, the devices can be programmed with sinus tachycardia discriminators turned on and patients should be encouraged to monitor HR with a portable device.

34 Practical Tip Rehabilitation and Exercise in HF Exercise Prescription and Exercise Modalities in HF Strength Training 1. For strength training, the use of light (5-10 lbs) free weights for repetitions 2 to 3 times per week may improve muscle tone and strength.

35 Back to Case 1 This man actually underwent hip replacement by another surgeon after a PET scan showed no ischemia and no significant viability (IMAGE-HF study 1A Ongoing) Of note, he had incessant VT under Hawaii blue skies (cruise) in October 2012 (ablated in Honolulu) - without loss of consciousness Left hip replacement in January 2013 Swimming 4 times a week in April 2013 Right hip replacement December , NYHA class I

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