The life after myocardial infarction: a long quiet river? Cardiac rehabilitation: for whom and how? Dr. Barnabas GELLEN MD, PhD, FESC Poitiers JESFC 2018 - Paris
Conflicts of interest Speaker honoraria Congress invitations NOVARTIS SERVIER ASTRA ZENECA NOVARTIS SERVIER ASTRA ZENECA BOEHRINGER
: for whom and how?
What do the guidelines say? IA recommendation for all MI patients European Heart Journal (2017) 00, 1 66
22% referral CR less likely if: female elderly NSTEMI [HR] 0.76; 95% CI 0.60 0.96 Arch Cardiovasc Dis 2016 Mar;109(3):178-87
Clinical benefit of CR - randomized studies 63 studies; N=14486; median follow-up 12 months 26% risk reduction for CV mortality OR 0.74; 95% CI: 0.64-0.86 J Am Coll Cardiol 2016;67(1):1 12.
CR use in the USA in 2007 CR use in 20.9 % after revascularized MI Circulation. 2007;116:1653-1662)
28.4% referral still low for a IA recommendation female still less likely to be referred Arch Cardiovasc Dis 2017 Nov 10. pii: S1875-2136(17)30203-6 (modified)
CR for all MI patients? Theory practice Factors of non-referral Patient-related Health system-related death / shock missed referral contraindication lack of knowledge lack of motivation lack of CR capacity fear of job / income loss CR accessibility Circulation 2011;124:2951 60
CR after MI not for whom? Cardiological Contraindications severe symptomatic AS / HOCM hemodynamic instability severe ventricular arrhythmia recent LV thrombus residual / recurrent angina Dressler significant pericardial effusion = same as for any exercise test
CR after MI not for whom? Non-Cardiological Contraindications ongoing / evolutive inflammatory disease recent deep venous thrombosis disabling neurological / muscular disease disabling osteo-articular problems dementia / cognitive dysfunction
Fake contraindications wrong / outdated beliefs non-revascularized coronary lesions culprit only strategy pre-existing asymptomatic lesions patients on β blocker maximal exercise test at enrolment No safety problem if no exercise-induced ischemia Comparable clinical benefit of CR Arch Cardiovasc Dis. 2017 Apr;110(4):234-241
Fake contraindications wrong / outdated beliefs Precapillary pulmonary hypertension Exercise training improves peak oxygen consumption and haemodynamics in patients with severe pulmonary arterial hypertension Eur Heart J. 2016 Jan 1;37(1):35-44 Effects of exercise training on pulmonary hemodynamics, functional capacity and inflammation in pulmonary hypertension Pulm Circ. 2017 Feb 1;7(1):20-37 No safety problem even if severe precapillary PH Attention to postcapillary PH after large MI sign of decompensated LV function (group 2 PH)
: for whom and how?
CR = secondary prevention centers 1) systematic and meticulous check for contraindications 2) check for exercise-induced ischemia / ventricular arrhythmia
CR = secondary prevention centers 3) individualized group-based exercise training aerobic endurance resistance gymnastics 4) individualized CV risk factor screening and control
evaluation of knowledge, lifestyle, compliance CR = secondary prevention centers 5) individualized therapeutic education programs Interactive workshops: nutrition, drug treatment, alert signs, travel, sports, sex 6) social and psychological assistance job / income loss, reorientation family / couple trauma / depression
Complex multidisciplinary care CR Sandesara, P.B. et al. JACC. 2015; 65(4):389 95
Complex multidisciplinary care physiotherapist social worker psychologist dietetician addictologist CR-cardiologist CR-nurse
Smoking cessation Arch Intern Med. 2008 Oct 13;168(18):1961-7 n=639 Am J Cardiol 2015;115:405-410 n=492 The strongest predictor of smoking cessation at 6 months after PCI was participation in cardiac rehabilitation OR 3.17, 95% CI 2.05 to 4.91, p <0.001) As compared to documented individual counseling, referral to CR multiplies the chance of sustained smoking cessation Similar results for compliance to drug treatment, dietary habits, etc.
Patient s perception of MI: extreme differences The terrified The careless Anxiety - depression Non-compliance Short ICU stay insufficient and inadequate to become aware of the illness and its consequences become aware of the required lifestyle modification MI = sudden and traumatic event The patient needs time and professional support to deal with it
CR = a psychologically secure and stabilizing environment for traumatized patients Comprehension Patience Counselling Motivation Respect Empathic listening Patients can take the time they need Exchange of experience with other patients
Initial evaluation Post-MI CR programs in practice Low-risk : «short and simple» no uncontrolled CVRF, preserved LVEF, no deconditioning, high socio-economic status Intermediate-risk : 2 months / 20-24 sessions active smoker, poor dietary habits, sedentary, overweight, depressive High-risk : In-patient 2 months / 20-24 sessions diabetic, elderly, multivessel, reduced LVEF, HFsymptoms, comorbidities Individually tailored program length and content
CR = secondary prevention center the «typical» schedule of a «typical» MI patient Hour Activity 9.00-9.30 Resistance training 9.30-10.00 Group gymnastics 10.00-10.30 Recovery break 10.30-11.00 Active relaxation 11.00-11.30 Endurance training 11.30-11.45 Recovery break 11.45-12.00 Consultation CR-cardiologist 12.00-13.30 Lunch break 13.30-14.00 Consultation smoking cessation 14.00-14.30 Workshop «nutrition» 14.30-15.00 Consultation psychologist 15.00-15.30 Workshop «drug treatment» hard work for the patient hard work for the CR-center
Endurance training modalities ordinateur central charges individuelles 100% 50-70% moderate continuous training, MCT 30% 10 20 30 min
Endurance training modalities Interval training (IT) 100% 10 20 30 min Clin Rehabil. 2012 Jan;26(1):33-44 Int J Cardiol. 2011 Nov 3;152(3):388-90
Exercise effects in ischemic heart disease antithrombotic / antiarrhythmic / anti-ischemic J Am Coll Cardiol 2015;65:389 95)
Exercise training Key issue: maintain of regular physical activity after discharge maintain of the functional benefits after CR Exercise can be viewed as a preventive medical treatment, like a pill that should be taken on an almost daily basis. Circulation 2013;128:873 934.
Perspectives for improving CR use Convince cardiologists of the benefits of CR Optimize referral system from the ICU to CR Increase ambulatory CR offer More dense territorial coverage Home-based CR for selected low-risk patients Telemedicine, telecoaching
Take home messages for young collegues consider CR as an integrated secondary prevention center go and see how your CR works discuss with your team how to optimize referral be aware of the recommendation class I level A be aware of the few real contraindications to CR give the same chance to female than to male MI patients give the same chance to elderly than to the young CONSIDER CR AS A PROFESSIONAL PERSPECTIVE FOR YOURSELF BECOME AN EXPERT IN EXERCISE PHYSIOLOGY / PATHOLOGY
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