Challenging clinical cases in cardiac rehabilitation: one size fits all? - women -

Challenging clinical cases in cardiac rehabilitation: one size fits all? - women - Prof. Dr. Birna Bjarnason-Wehrens Institute for Cardiology and Sports medicine German Sportuniversity Colgne

Sex differences in clinical profiles Compared to male counterparts female patients diagnosed with coronary artery disease are - at older age - at higher cardiovascular risk and more often diagnosed with - hypertension (> 45 year of age) - diabetes mellitus - hypercholesterolemia - obesity (> 45 year of age ) - metabolic syndrome Grundy et al. Circulation 2004; 110 227-239 - heart failure (> 65 year of age) Rosengren et al. Eur Heart J 2004 25:663-70. -more likely to experience exercise limitations and other co-morbid conditions Blomkalns et al. J Am Coll Cardiol 2005 ;45:832-7. Hochman et al. N Engl J Med 1999;341:226-32 Differences documented in medical treatment, course of the disease, short and long-term prognosis Stramba-Badiale Eur Heart J 2006 27 994-1005

Do Men and Women Achieve Similar Benefits From Cardiac Rehabilitation? Todaro et al. J Cardiopulm Rehabil 2004;24:45-51 Sex differences in clinical profiles at entry to cardiac rehabiliation (women vs. men) - Hypertension (73-78% vs. 39-46%) - Diabetes mellitus (30-33% vs. 10-20%) - Less favourable lipid profiles - Lower exercise capacity and exercise tolerance - Lower perceived exercise tolerance - Less recreational exercise activities older women in particular - more likely to experience activity limitations and other exercise-limiting co-morbid conditions (i.e. arthritis, osteoporosis, urinary incontinence)

Do Men and Women Achieve Similar Benefits From Cardiac Rehabilitation? Todaro et al. J Cardiopulm Rehabil 2004;24:45-51 Sex differences in socio demographical profiles at entry to cardiac rehabilitation (women vs. men) - Female ca. 10 years older than male patients - Marital status - living with a partner (29-59% vs. 74-91%) - Employed status (39% vs. 70%) - Lower levels of education - Fewer sources of social support

Do Men and Women Achieve Similar Benefits From Cardiac Rehabilitation? Todaro et al. J Cardiopulm Rehabil 2004;24:45-51 Sex differences in clinical profiles at entry to cardiac rehabilitation (women vs. men) Results indicate that women may - have lower self-efficacy related to exercise and health behaviour changes - experience more stress at home - exhibit higher anxiety - have reduced quality of life (SF-36) - lower energy levels - more functional and psychosomatic problems - Lower health functioning - Low scores on the physical component

Do Men and Women Achieve Similar Benefits From Cardiac Rehabilitation? Todaro et al. J Cardiopulm Rehabil 2004;24:45-51 Sex differences in cardiac rehabilitation referral patterns and utilisation - Women tend to underutilise cardiac rehabilitation Women are less likely to participate in CR than men with similar clinical profiles (older women 15% vs. 25% older men) Women are less likely to receive information about CR CR is less strongly recommended to women by physicians (age; low exercise tolerance; co-morbid medical conditions) Women have lack of familiar, spousal support; less encouragement from health professionals Women are more likely to have transportation and/or financial problems Women have more familiar and social commitments When women participate in CR however there is no convincing evidence that they tend to be less adherent to the CR regime

Do Men and Women Achieve Similar Benefits From Cardiac Rehabilitation? Todaro et al. J Cardiopulm Rehabil 2004;24:45-51 Sex differences in CR outcomes: - Women achieve similar benefits from CR like men regarding - risk factor modification - improved exercise capacity and exercise tolerance - Results indicate more or less sex differences in CR results regarding - Quality of life? - Symptoms of anxiety? - Symptoms of depression? Further investigations are needed

Contemporary trends in cardiac rehabilitation in Germany: patient characteristics, drug treatment, and risk-factor management from 2000 to 2005. Bestehorn et al. Eur J Cardiovasc Prev Rehabil 2008;15:312-8 German register study results from 117 983 patients attending in-patient CR (171 different CRcentres) 30% female patients at entry to cardiac rehabilitation - older age (68,0 vs. 63,3 years) - reduced exercise capacity (61.3 vs. 84.6 watt) - higher BMI-, glucose- und blood lipid levels (28.6 vs. 28,1; 109,5 vs. 105,8 mg/dl; LDL 133,5 vs. 126,9 mg/dl) - less often treated with ASS and ACE-inhibitors (76,1 vs. 79,7%; 65, 7 vs. 74,2%) Both sexes achieved similar benefits from the CR participation (BP < 140/90 81,8 vs. 83,0% - LDL< 100 TG <180 54,2 vs. 54,6% - 87,2 vs. 101,9 watt)

Patient Orientation in Rehabilitation The Gender Perspective Mittag & Grande Rehabilitation 2008;47:98-108 Gender specific CR goals and preferences Men: To resolve disease related occupational problems To clarify retirement pension related questions To improve convalescence To improve expectancy of life To improve exercise capacity and exercise tolerance To improve endurance capacity and muscular strength

Patient Orientation in Rehabilitation The Gender Perspective Mittag & Grande Rehabilitation 2008;47:98-108 Gender specific CR goals preferences Women: To recover and gain relief from burden of daily life (therefore preferring in-patient CR) To receive emotional und social support To receive psychological support in coping with the disease To receive optimal medical treatment To reduce weight; weight control Retrospective: different types of exercise training not leading to immoderate exhaustion or pain

Gender specific cardiac rehabilitation goals and preferences Do traditional CR programmes meet the needs and preferences of (older) women? Do women need specially tailored CR programmes? Do we need special programmes designed for women only? A better integration of women-specific subjects and views in the design and organisation of CR could enhance women`s motivation and adherence.

A cardiac rehabilitation program to improve psychosocial outcomes of women with heart disease Davidson et al. J Womens Health 2008 Jan-Feb;17(1):123-34 The Heart Awareness for Woman Program (HAFW) A nurse directed CR program tailored to the needs of women following acute cardiac event to address their psychological and social needs Study group: 48 women, aged 42-80 years (67.4% married; 60.5% living with partners; 12% cared for people living outside of their home; 16.6% in paid employment) Intervention: 6 weeks - 2 h per week nurse lead discussions in small groups (5-10 women) - guided support-group with prepared topic schedule allowing flexible discussion Topics schedule: 1. heart disease in women, 2. coping with multiple and changing roles, 3. activity and exercise, your daily schedule, 4. depression and anxiety awareness of signs, 5. coping with challenge and stress, 6. communicating effectively.

A cardiac rehabilitation program to improve psychosocial outcomes of women with heart disease Davidson et al. J Womens Health 2008 Jan-Feb;17(1):123-34 The Heart Awareness for Woman Program (HAFW) Instruments (before and after intervention): - Perceived Control (The Cardiac Control Index) - Depression, anxiety and stress (Depression Anxiety, Stress Scale short form (DASS)) - Role Integration (Women's Role Interview Protocol (WRIP)) - Social support (The Multidimensional Scale of perceived Social Support (MSPSS)) Results: Quantitative: no significant changes from pre- to post-intervention in any of the instruments used

A cardiac rehabilitation program to improve psychosocial outcomes of women with heart disease Davidson et al. J Womens Health 2008 Jan-Feb;17(1):123-34 Qualitative results: Lack of understanding/awareness of symptoms - patient herself family friends health professionals Isolation being alone with the experience of the disease family and friends could not understand what they were going through Not prioritizing own health putting the needs of others before their own often at the expense of their own health feeling emotionally und physically exhausted from being there and doing sth. for others not having the time for exercise or stress minimization strategies because of their multiple roles

A cardiac rehabilitation program to improve psychosocial outcomes of women with heart disease Davidson et al. J Womens Health 2008 Jan-Feb;17(1):123-34 Qualitative results Benefits of support and supportive education/awareness: The women experienced it as helpful to be able to talk about subjects relevant to their heart condition in a way that was not possible with their families or friends - to freely discuss unique problems women face following cardiac diagnosis i.e. experiencing incontinence The open frank discussion served to ease the feelings of anxiety and loneliness The women felt reassured that they were not alone in their concerns and challenges The women did not feel overloaded with by information they received because they hat the opportunity to process it, ask questions and hear perspectives of the other women in the group The women appreciated the contact with knowledgeable CR nurses together with her, they were able to work out personal strategies for (lifestyle) changes needed

A cardiac rehabilitation program to improve psychosocial outcomes of women with heart disease. Davidson et al. J Womens Health 2008 Jan-Feb;17(1):123-34 Consequence for cardiac rehabilitation to enhance women`s motivation and adherence? Integration of women-only guided support groups in cardiac rehabilitation programs? More time for questions and discussion (i.e. with the physician) and more time for guided group discussion, within the educational and psychosocial elements of the CR program? More working in small groups (education; psychosocial elements)?

Patient Orientation in Rehabilitation The Gender Perspective Mittag & Grande Rehabilitation 2008;47:98-108 Retrospective: different type of exercise training not leading to immoderate exhaustion or pain Do women need specially tailored exercise training in CR? Taking into account their special needs and requirements based on - lower exercise capacity and exercise tolerance - lower perceived exercise tolerance - less recreational exercise activities - more activity limitations and other exercise-limiting co-morbid conditions - activity preferences

Aerobic capacity in patients entering cardiac rehabilitation Ades et al. Circulation 113 (2006);2706-12 n = 2896 patients 815 women (28%) 62 11 years 2081 men (72%) 61 11 years Peak VO 2 at entry to cardiac rehabilitation: women = peak VO 2 14.5 3.9 ml. kg -1. min -1 (p<0.0001) men = peak VO 2 19.3 6.1 ml. kg -1. min -1

Aerobic capacity in patients entering cardiac rehabilitation Ades et al. Circulation 113 (2006);2706-12 peak VO2 ml. kg-1. min-1 Cardiac diagnosis women men PCI without myocardial infarction 15.1 4.1 21.2 7.2 Myocardial infarction 14.7 4.2 20.4 6.6 Unstable angina pectoris 14.7 3.8 18.3 5.8 Bypass-surgery 13.5 3.4 17.8 4.8

Aerobic capacity in patients entering cardiac rehabilitation Ades et al. Circulation 113 (2006);2706-12 n = 504 patients, 118 women 386 men Changes in peak VO 2 mediated by the CR (36 exercise units in 3 months) Study group: 18.3 5.9 to 21.4 6.8 ml. kg -1. min -1 (p<0.0001) 17% men + 3.4 4.2 ml. kg -1. min -1 (p< 0.0001) 18% women + 1.8 3.9 ml. kg -1. min -1 (p< 0.0001) 12%

Randomized trial of progressive resistance training to counteract the myopathy of chronic heart failure. Pu et al. J Appl Physiol 90 (2001):2341-50 Study design: Randomized controlled trial including skeletal muscle biopsy Interventional group = 9 women, 76.6 2 years, LV EF 36.3 2.7% Control group = 7 women, 76.6 2.4 years, LV EF 36.3 2.7% Training: high intensity progressive resistance training Duration: 3 days per week for 10 weeks 5 different exercises Intensity of training: 80% 1RM, three sets of eight repetitions each Placebo control group: 2 days per week supervised, low-intensity stretching exercises without resistance Results: Peak VO 2 ; LVF 6-minutes walking distance 49% vs. -3% Muscle strength 43% vs. 1.7% Muscle endurance 29% vs. 1% Muscle mass Type I fibres 15.6% vs. -6% Type II fibres ; Oxidative enzyme capacity

Maintenance of an independent lifestyle as on of the main CR goals Since older women are more often living alone at the time of cardiac event improvement in functional capacity to perform everyday activities of dally life may be the most crucial cardiac rehabilitation outcome for them. Enhancement of flexibility, muscle strength, coordination and balance is important with respect to maintenance of independent lifestyle

Predictors of Women`s Exercise Maintenance After Cardiac Rehabilitation Moore et al. J Cardiopulmonary Rehabilitation 2003; 23;40-49 Study group: 60 women (64.8 ± 10.3 years) recruited at completion of phase II CR Exercise measured using a heart rate wristwatch monitor over 3 months Previous exercise experience as an adult 28.3% Results: - 25% did not exercise at all following completion of CR - only 48% were exercising at 3 months - only 27.3% were exercising regularly 3 times weekly - mean exercise frequency at the target heart rate was 5.2 units in 3 months

Predictors of Women`s Exercise Maintenance After Cardiac Rehabilitation Moore et al. J Cardiopulmonary Rehabilitation 2003; 23;40-49 Predictors of exercise maintenance: - exercise frequency: co-morbidity, instrumental social support, - exercise persistence: instrumental social support - exercise intensity: co-morbidity - exercise total amount: benefits/barriers Conclusions: Interventions aimed at increasing women s physical activity should focus on increasing their problem-solving abilities to reduce barriers to exercise and increase social support by family and friends Special attention has to be paid to co-morbidity while advising women to exercise and in individual exercise prescriptions for female patients

Topics for cardiac rehabilitation in women 25-50% of all women aged > 60 years suffer from urinary incontinence. Most of these women suffer from stress leakage, and physical activities can cause urinary accidents could be a barrier to physical activities especially to group activities in the cardiac rehabilitation of women this has to be addressed pelvic floor exercises should be integrated

Topics for cardiac rehabilitation in women 30% of all postmenopausal women suffer from osteoporosis Risk of falls is higher in patients with reduced muscle mass and body coordination Consequences for exercise training in cardiac rehabilitation pay special attention to risk of injuries and falls! integrate training of body coordination integrate adequate resistance exercise

Different symptoms of angina pectoris and heart attack -Women are more likely to experience "atypical" symptoms of angina than men, such as a hot or burning sensation, or even tenderness to touch, in the back, shoulders, arms or jaw; often they have no chest discomfort at all. -Heart attacks also tend to occur differently in women. Frequently they experience nausea, vomiting, indigestion, shortness of breath or extreme fatigue, but no chest pain. -Women also are more likely than men to have "silent" heart attacks.

Physical activity and exercise training in women Women tend to repress signs of overexertion and to underestimate the actual effort level Women often not tell about symptoms or not well being wait until this is addressed by the therapist Training of bodily perception to improve load sensibility and load evaluation is important.

Main contents of exercise training in women Training of bodily perception to improve load sensibility and load evaluation in daily life activities, and recreational activities as well as in physical activities and exercise training Training of body coordination to work against age related reduction and to reduce risk of falls and injuries Resistance exercises (osteoporosis-prophylaxis) exercises for abdominal, back, pelvic and pelvic floor muscle Endurance training with walking, Nordic walking, biking, swimming - in older women (aged 65-97 years) walking is the most popular physical activity

Sex specific aspects in cardiac rehabilitation What do we know? We know that sex specific differences do exist in clinical, psychological and sociodemographic profiles and that these differences have to be considered in the implementation of cardiac rehabilitation programmes There is a lack of evidence about the impact of these sex specific differences on the - participation and adherence to cardiac rehabilitation programmes - efficiency of participation Women do have different preferences and do at least in some fields (seem to) need special and different care and attention by health professionals during cardiac rehabilitation

Sex specific aspects in cardiac rehabilitation Based on current knowledge we have not enough evidence to define exactly the specific needs of women to improve their participation and the efficacy of cardiac rehabilitation programme offered To be able to indentify these specific needs, more high quality investigation in this field is needed Based on their results specific therapeutic interventions for women can be developed and their efficiency in participation, adherence and all target outcomes variables of cardiac rehabilitation programmes have to be verified There is a long way to go but the first step is to realise that there are sex specific differences in not only clinical but also psychological and socio-demographic profiles and cardiac rehabilitation goals and preferences as well - that have to be considered

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. Piepoli et al. Eur J Cardiovasc Prev Rehabil 2010 Feb;17(1):1-17 Cardiac rehabilitation in women - Core components Components Established /Generally Agreed Issues Class (Level) Patient Assessment Clinical history: (see also Table 10) Patient education is crucial to provide comprehensive information on the contents and the basic purpose of the CR programme to improve adherence and reduce possible barriers. Physical Activity Counselling advise and encourage to perform regular physical activities (e.g. walking or biking > 30 min 5-7 days a week). women who need to lose weight or sustain weight loss should accumulate a minimum of 60 to 90 minutes of moderate-intensity physical activity (eg, brisk walking) on most, and preferably all, days of the week emphasise participation in supervised group activities to advance social integration and support. Exercise training Exercise recommendations and prescriptions (see also Table 10) allow individual convenience and preferences which might be different from those of male patients, include combined programme of endurance (cycle, walking, Nordic walking) and resistance exercise (major functional, postural and pelvic flour muscle) include callisthenics to develop flexibility, coordination (balance skills) and, body awareness include activities and games which enhance communication and social integration. I (B) I (C) I (A) Smoking cessation Psychosocial management Women should not smoke and should avoid environmental tobacco smoke. Provide counselling, nicotine replacement, and other pharmacotherapy as indicated in conjunction with a behavioural program or formal smoking cessation program women might need more individual support. Focus on treatment of anxiety and depression, improvement in social readaptation and reintegration as well as overall quality of life Emphasize on emotionally supportive approaches. Female patients respond positively to reassurance, encouragement and mere listening I (B) IIa (B)

Thank you for your attention