Cardiac Rehabilitation after Primary Coronary Intervention CONTRA

DEBATE SESSION Is there a role for cardiac rehabilitation in the modern era of Percutaneous coronary intervention and coronary artery bypass grafting? Cardiac Rehabilitation after Primary Coronary Intervention CONTRA Robbert J de Winter MD PhD FESC Professor Clinical Cardiology Academic Medical Center University of Amsterdam AMC Amsterdam Interventional Cardiology

No Conflicts of interest AMC Amsterdam Interventional Cardiology

Debate on Cardiac Rehabilitation I am not an expert Interventional cardiologist Involved in ppci Pre-Hospital triage in Amsterdam My daily practice Organize logistics with ambulance services Total Ischemic Time, Call-to-Needle Time Thrombectomy, stents, DAPT Benchmarks: effective timely reperfusion AMC Amsterdam Interventional Cardiology

Debate on Cardiac Rehabilitation Most patients from referring hospitals Communicate with referring cardiologists Regional protocols Outpatient FU done elsewhere Secondary prevention Medical therapy at discharge Outpatient clinic AMI - follow up Lifestyle recommendations Physical exercise program AMC Amsterdam Interventional Cardiology

Debate on Cardiac Rehabilitation Directive from Dutch Health Authority: Too few patients referred for Cardiac Rehab Less than 40% I needed to study My knowledge from literature / web search Evidence for Cardiac Rehab? Evidence for Cardiac Rehab in ppci patients? Reviews, Meta-analyses, Patients Reports AMC Amsterdam Interventional Cardiology

Debate on Cardiac Rehabilitation I am a Sceptic: Physocial well-being boosts Immune System Positive Affect associated with Quality of Life Happiness associated with Forearm Blood flow I am on the Defence: My work is taken over by Nurses and Paramedics Nurse-Practicioners for Cathlab procedures Nurses do Sec Prev, DM, Hypertension, PCI-FU Physiotherapists, psychologists, dieticians, work-out coaches So I can spend more time to sit at a keyboard to type reports and discharge letters AMC Amsterdam Interventional Cardiology

AMC Amsterdam Interventional Cardiology

Cardiac Rehabilitation Recommended by the guidelines Large body of scientific evidence Performance measure used by health authorities Dedicated scientific journals Major industry : Many hundreds In-patient and out-patient programs in Europe Many thousands of patients in Europe with AMI, CABG, PCI, Heart failure, etc. Many thousands of health care professionals make a living, working in cardiac rehabilitation programs Patients request referral, programs are reimbursed AMC Amsterdam Interventional Cardiology

Rehabilitation is aimed at restoring the patient to as full a life as possible, including return to work. It must take into account physical, psychological, and socio-economic factors. Rehabilitation should be offered to all patients after STEMI. AMC Amsterdam Interventional Cardiology

AMC Amsterdam Interventional Cardiology

Strategy Debate on Cardiac Rehabilitation Pro Con Sessions: Create confusion (definitions, semantics) Argue that most studies are outdated Studies did not include patient population (ppci) Demand double-blinded RCTs (possible or not) Criticize control groups, methods, investigators Downplay proven magnitude of effects Argue that clinical practice is different from studies Question the opponent: Motives, interests, credibility AMC Amsterdam Interventional Cardiology

Cardiac Rehabilitation vs Secondary Prevention Cardiac rehabilitation is defined as a multidisciplinary program consisting of exercise, risk factor modification and psychosocial intervention, forms an integral part of managing patients after myocardial infarction. Secondary prevention is defined as comprehensive risk factor management to reduce risk as assessed by a variety of outcomes, including improved survival, reduced recurrent events and improved quality of life. - Smoking cessation - Glucose control - Blood pressure control - Weight management - Lipid management - Antiplatelets - Physical activity - Betablockers AMC Amsterdam Interventional Cardiology

Debate on Cardiac Rehabilitation Is a multidisciplinary program consisting of exercise, risk factor modification and psychosocial intervention proven beneficial in patients after primary PCI? AMC Amsterdam Interventional Cardiology

Drive through PCI

The impact of comprehensive cardiac rehabilitation in patients up to 55 years old after acute myocardial infarction treated with primary coronary intervention N = 71 patients 31 CR vs 40 controls At 6-months follow-up chest pain and symptoms of heart failure were significantly less common (p < 0.001) and a tendency for fewer new cardiac events and re-pci was noted in CR. Self-evaluated, significantly greater improvement in the emotional and physical status as well as in physical activity (p < 0.001) was achieved in CR. In CR better exercise tolerance on treadmill exercise test, greater improvement in left ventricular ejection fraction (p < 0.05) and contractile index (p < 0.05) on echocardiography were observed. The effects of the secondary prevention in terms of smoking cessation and obesity were not satisfactory in both groups. Piestrzeniewicz et al. Pol Arch Med Wewn. 2004 Mar;111(3):309-17. AMC Amsterdam Interventional Cardiology

Drive through PCI

Drive through PCI 47 studies 10,974 patients

Total Mortality Drive through PCI 0.82 (0.67 1.01)

> 12 months 0.87 (0.75 0.99)

Cardiovasc. Mortality 0.93 (0.71 1.21)

> 12 months 0.74 (0.63 0.87)

Fatal or nonfatal MI 0.92 (0.70 1.22)

Hospital admissions 0.69 (0.51 0.93)

Authors conclusions Exercise-based cardiac rehabilitation is effective in reducing total and cardiovascular mortality (in medium to longer term studies) and hospital admissions (in shorter term studies) but not total MI or revascularisation (CABG or PTCA). Despite inclusion of more recent trials, the population studied in this review is still predominantly male, middle aged and low risk. Therefore, well-designed, and adequately reported RCTs in groups of CHD patients more representative of usual clinical practice are still needed.

My conclusions Most of the studies were small Studies are outdated positive effects 1975 / 1979 / 1983 No ppci AMI patients included Effect of cardiac rehabilitation is small Concerns about blinding, definition of programmes Concerns about lost to follow up Not relevant to my practice

English Fellow: Did you hear about the RAMIT trial?

NHS funded study A multi-centre RCT in representative hospitals in England and Wales compared 1813 patients referred to comprehensive cardiac rehabilitation programmes or discharged to usual care The primary outcome measure was all-cause mortality at 2 years The secondary measures were morbidity, health service use, health related quality of life, psychological general well-being and lifestyle cardiovascular risk factors at 1 year

Inclusion 1997 2000 14 hospitals follow-up of secondary outcomes to 2001 and of vital status to 2006 Sample size 8000 patients to demonstrate 20% RRR in all-cause mortality at 2 years Trial prematurely discontinued on request of the sponsors (National Health Service (NHS) Research and Development Programme) 903 patients rehabilitation vs 910 patients control

Rehabilitation after AMI, the RAMIT trial

Survival following admission for acute myocardial infarction. West R R et al. Heart doi:10.1136/heartjnl-2011-300302 Copyright BMJ Publishing Group Ltd & British Cardiovascular Society. All rights reserved.

Rehabilitation after AMI, the RAMIT trial

Conclusions No effect on mortality at 1 year, 2 year or 7-9 years Little evidence of any beneficial effect on morbidity, cardiac medication, risk factors, lifestyle or patients appreciation of total aftercare Rehabilitation programmes may contribute to seamless patient care and they are appreciated by many patients but evidence of objective benefit is weak relative to the proven benefits from other aspects of cardiac management Trial done in the modern era of Thrombolysis

Thank You

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