Is cardiac rehabilitation necessary? M. Ghannem CPRCV Ollencourt Léopold Bellan UCI - CH Gonesse
No conflic of interest
Is cardiac rehabilitation necessary? Is cardiac rehabilitation recommended.
Is coronary revascularisation STEMI nécessary?
Percentage of deaths at 30 days Evolution of mortality at 30 days according to the method and type of reperfusion No reperfusion Thrombolysis Coronary angioplasty FAST- MI 2012
Guidelines from the Européen Society of Cardiology 2012 Coronary revascularisation STEMI Is nécessary
Is réhabilitation After STEMI nécessary?
FAST MI 2005 ( 5 - year survival) 3670 patients réhabilitation No réhabilitation (20%) Iliou MC, Danchin N. AHA 2012
Participation in Cardiac Rehabilitation, Readmissions, and Death After Acute Myocardial Infarction 2991 STEMI + (1987-2010) : 52% patients rehabilitation Mortality: - 42% Dunlay S Am J Med (2014) 127, 538-546
Guidelines from the Européen Society of Cardiology 2012 ESC 2012 STEMI
Guidelines from the French Society of Cardiology 2010 CAD (except surgery) Class Level ACS «stabilized» - Exercise evaluation -Secondary Prevention -Therapeutic Education -Ambulatory if possible I A After scheduled angioplasty -Exercise evaluation -Not over-risk -Secondary Prevention -Therapeutic Education -Ambulatory if possible I B Stable angina -Exercise evaluation -Therapeutic Optimisation I B -Secondary Prevention -Therapeutic Education -Ambulatory if possible
Percentage of patients with STEMI Change in practice: reperfusion of patients with STEMI* years PCI increase : 12% à 61% Réhabilitation : 20 à 30 % No revascularisation : 25 % No Réhabilitation : 70% FAST- MI 2012
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EXERCISE ECG
Safety 3132 patients with coronary stenting within the last 12 months 44 cardiac centres réhabilitation.. Iliou MC. Eur J Prev Cardiol 2015;22:27-34
Survie sans événements cardiovasculaires Post ATL + ou - readaptation 108 Patients à 3 ans Réadaptation Contrôle BELARDINELLI R, J Am Col Cardiol 2001; 37 : 1891-1900
Impact Of Cardiac réhabilitation on Mortality and Cardiovascular Events After PCI 2395 pts PCI 1994 to 2008 Follow -op 6.3 years 40% Cadiac réhabilitation 45 % overall mortality 31 % cardiac mortality 27 % Death or MI Goel K, Circulation 2011;123: 2344-2352
Stenting, physical training (PT) and endothelial function PT: + 5.2 % T : - 0.1 % P : 0.01 Munk et al Am Heart J. 2009 Nov; 158(5) : 734-41
Survival After Coronary Artery Bypass Graft Surgery 846 pts, 69 % CR Follow op 10 years, RR réduction in all cause mortality 46 % Absolute risk reduction of 12.7% Quinn R. Pack. Circulation. 2013; 128: 590-597
failure : patients profil has changed progressive decrease of age from 66 to 63 years MEN WOMEN Regular smokers Obesity 75 y Men 60-74 y < 60 y Women FAST- MI 2012
But incidence (STEMI) not decrease increase? Mortality Incidence MONICA 1997-2002 Wagner A et al Bull Epidemiol Hebdo 2006; n 8-9:65-66
if we want to decrease CAD incidence we should rehabilite our patients Studies prove it
FAST MI Results: secondary prevention treatment at 1 year Individual classes at 1 year Co
Effect of endurance training on vascular risk factors, hemodynamic, and hormones Meta-analysis 72 studies 3 936 Patients with and without hypertension Exercise 4 weeks Vascular resistance plasmatic Renin activity Norepinephrin Weight Waist circumference insulin resistance Lipids HDL Blood pressure 7.1 % 20% 29% 1.2 kg 2.8 cm 0.31 U 1.4% + 0.0032 6.9/ 4.9 HTA 1.9 / 1.6 P < 0.05 0.001 0.01 0.01 0.001 0.001 0.001 0.05 0.001 Véronique A et al., Hypertension, 2005
6 meta-analyses since 2000. 71 randomized clinicals trials ( n: 13824 Pts) - 20 % significant positive changes in modifiable risk factors (total cholesterol, triglycerides and systolic blood pressure) - 25 % Oldridge N. Future Cardiol 2012;8:729-51
Participation in Cardiac Rehabilitation, Readmissions, and Death After Acute Myocardial Infarction 2991 STEMI ( 1987-2010 ) 52% patients rehabilitation Ré hospitalisation : -25% Dunlay S Am J Med (2014) 127, 538-546
47 studies randomising 10,794 patients Overall mortality : 13 % Cardiovascular mortality : 26% Not reduce the risk of total MI, CAGB or PTCA Hospital admissions : - 31% ( < 12 mois) 10 trials reporting health-related quality of life Heran et al: Cochrane database sys.review 2011 Jul 6;(7):CD001800
Cost (SEK) of post MI rehabilitation vs Control group Intervention group N = 147 Control group N = 158 Difference Physical training program 1530 0 1530 Rehospitalisation 22480 31050-8570 Clinical follow-up 5220 4090 1130 By pass surgery 5450 5730-280 drugs 2880 2530 350 Cost of training 1730 0 1730 Cost of medical visit 950 750 200 Direct total cost 40240 40150-3910 time of training cost 990 0 990 time of visits cost 330 310 20 Lost of production (work stoppage) 442700 513310-70610 Total cost 484260 557770-73510 LEVIN LA, et al J Int Med 1999 ; 230 : 427
Physical training increase the coronary flow reserve ( FFR - CFR)
PET (101 patients) Comparison angioplasty versus Physical training Results at 1 year 80% 75% 70% 65% Scintigraphie myoc initiale at 0 Scintigraphie myoc at à 12 12 mois months 60% 55% Entrainement Réhabilitation Angioplastie PCI Myocardial perfusion during demake-up exercise myocardial scintigraphy in CAD patients. Same decrease of LV perfusion defect in both groups HAMBRECHT R, Circulation 2004; 109: 1371-8
Endothelial Activation Growth factors Physical exercice Hypoxia + pressure gradient Endothelial activation and growth factors Neo angiogenesis and arteriogenesis (Collateral Circulation)
Endothelial Cells: Nitric oxyde (NO) Ca 2+ L-Arginine NO-Synthase O 2 Citrulline Relaxation Cellule Endothéliale Hyperpolarisation NO Ca 2+ K + GMPc Guanylate Cyclase GTP Réticulum Sarcoplasmique Cellule Musculaire Lisse
Non-invasive Visualisation of the LAD by color flow Doppler by transthoracic echocardiography
Non-invasive CFR by transthoracic Doppler echocardiography CRF : 2,9 Concordant High CFR and FFR
Non-invasive CFR by transthoracic Doppler echocardiography CRF : 1,6 Concordant Low CFR and FFR
Correlation between invasive FFR and non-invasive CFR
Correlation between non-invasive CFR and exercise capacity
Pronostic value of exercise capacity with or without history of CV events Each 1 MET is associated with of 13% of mortality 6749 blacks 8911 whites KOKKINOS P., MYERSJ. Circulation 2008;117:614-622
Cardiac réhabilitation Decreases morbi-mortality Improves vascular risk factors profil Improves physical workload, activity Improves quality of life Decreases cost management of CAD Is cardiac rehabilitation necessary? YES
Conclusion Recent guidelines in the UK and USA have concluded with the recommendation that cardiac rehabilitation is reasonable and necessary and should be promoted by healthcare professionals, including senior medical staff Oldridge N. Future Cardiol 2012;8:729-51
THANK YOU FOR YOUR ATTENTION THE FUTURE DRUGS, PREVENTION, and READAPTATION Will replace ANGIOPLASTY PERCUTANEOUS ANGIOPLASTY Will replace SURGERY