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					Cardiac Rehabilitation
            Introduction
 Up  until the 1950s, strict bed rest
  was thought to be the best
  medicine after a heart attack.
 Following discharge moderately
  stressful activity such as climbing
  stairs was discouraged for a year or
  more.
             Introduction
"The patient is to be guarded by day
 and night nursing and helped in
 every way to avoid voluntary
 movement or effort."

Thomas Lewis, 1933
            Introduction
 Despite the known benefits of
 cardiac rehabilitation (CR) and
 widespread endorsement (CR) is
 vastly underutilized and less than
 30% of patients participate in CR
 programs after a CV event.
                         Overview
   What is cardiac rehab
       Components, Terminology & Contraindication
       Safety
   Medicare Coverage
   Evidence
       STEMI UA/NSTEMI
       Stable angina & Percutaneous coronary intervention
       Coronary bypass surgery
       Heart failure
   Rehab Options at UIC and in IL
   Conclusions
What is Cardiac Rehab?
                           Definition:
   Cardiac rehabilitations services are
    comprehensive, long-term programs involving
       medical evaluation,
       prescribed exercise,
       cardiac risk factor modification,
       educations and counseling.
   These programs are designed to limit the
       physiologic and psychological effects of cardiac illness,
       reduce the risk for sudden death or reinfacrction,
       control cardiac symptoms, stabilize or reverse the
        atherosclerotic process,
       and enhance the psychosocial and vocational status of selected
        patients
     American Association of
 2007
 Cardiovascular and Pulmonary
 Rehabilitation/AHA/ACC
 Guidelines
     Performance Measures on Cardiac
      Rehabilitation for Referral to and Delivery of
      Cardiac Rehabilitation/Secondary Prevention
      Services:
       Cardiac Rehab Terminology
   Phase 1: Inpatient Rehab - A program that
    delivers preventive and rehabilitative services to
    hospitalized patients following an index CVD
    event
   Phase II: Early outpatient CR - a programmed
    that delivers preventive and rehabilitative
    services to patients in the outpatient setting
    early after CVD event within the first 3-6 months
    and continuing for up to 1 year
   Phase III: Long-term outpatient CR - Longer
    term delivery or preventive and rehab
        Cardiac Rehab Terminology
   Risk Stratification for Exercise
     Class A
     Class B

     Class C

     Class D




           Guidelines published by the American Heart Association use four
            categories of risk according to clinical characteristics
      Cardiac Rehab Terminology
   Class A: apparently healthy and no clinical evidence of
    increased cardiovascular risk of exercise.
   Class B: established CHD that is clinically stable.
    Overall low risk of cardiovascular complications of
    vigorous exercise.




           Guidelines published by the American Heart Association use four
            categories of risk according to clinical characteristics
      Cardiac Rehab Terminology
   Class C: moderate or high risk of cardiac complications
    (multiple myocardial infarctions or cardiac arrest,
    NYHA class III or IV, Exercise capacity of < 6 METs,
    or significant ischemia on the exercise test.
   Class D: unstable disease for whom exercise is
    contraindicated.

           Guidelines published by the American Heart Association use four
            categories of risk according to clinical characteristics
          Absolute Contraindication to
                   Exercise
   Absolute Acute myocardial infarction (within two days)
   Unstable angina
   Uncontrolled cardiac arrhythmias causing symptoms or homodynamic
    compromise
   Symptomatic severe aortic stenosis
   Uncontrolled symptomatic heart failure
   Acute pulmonary embolus or pulmonary infarction
   Acute myocarditis or pericarditis
   Active endocarditis
   Acute aortic dissection
   Acute noncardiac disorder that may affect exercise performance or be
    aggravated by exercise
   Inability to obtain consent


Exercise standards for testing and training: a statement for healthcare professionals from
   the American Heart Association. Circulation 2001; 104:1694
Relative Contraindication to Exercise
   Left main coronary stenosis or its equivalent
   Moderate stenotic valvular heart disease
   Electrolyte abnormalities
   Severe hypertension (systolic 200 mmHg and/or diastolic 110
    mmHg)
   Tachyarrhythmias or bradyarrhythmias, including atrial
    fibrillation with uncontrolled ventricular rate
   Hypertrophic cardiomyopathy and other forms of outflow tract
    obstruction
   Mental or physical impairment leading to inability to cooperate
   High-degree atrioventricular block

        Exercise standards for testing and training: a statement for healthcare professionals from
          the American Heart Association. Circulation 2001; 104:1694;
     Cardiac Rehab Terminology
   Content and duration : Each exercise session
    includes three phases:
        Warm-up for 5 to 10 minutes. Warm-up exercises consist
         of stretching, flexibility movements
        Conditioning or training phase, which consists of at least
         20 minutes and preferably 30 to 45 minutes of continuous
         aerobic activity.
        Cool-down for 5 to 10 minutes. permits a gradual
         recovery from the conditioning phase.
            Cardiac Rehab
 Omission of cool-down can result in a transient
  decrease in venous return, reducing coronary blood
  flow when heart rate and myocardial oxygen
  consumption remain high.
 Adverse consequences can include hypotension,
  angina, ischemic ST-T changes, and ventricular
  arrhythmias.
          Maximum Heart Rate
   Estimated as 220 minus the age in years (most
    common)
   Maximum heart reached at peak exercise during
    a symptom-limited exercise tolerance test
Cardiac Rehab Exercise Intensity
   Exercise intensity has been categorized using the
    percent HRmax as:
   Light (<60 percent)
   Moderate (60 to 79 percent)
   Heavy (80 percent)
   The incremental benefit of very high intensity
    exercise (>90 percent of HRmax) is small and is
    not recommended
               Cardiac Rehab

   Patients with stable angina may have an exercise
    prescription based upon 60 to 70 percent of the
    heart rate at which ischemic ST segment changes
    or anginal symptoms appear.
Extra Marital sex
                            Overview
   What is cardiac rehab
       Components, Terminology & Contraindication
       Safety
   Medicare Coverage
   Evidence
       STEMI UA/NSTEMI
       Stable angina
       Percutaneous coronary intervention
       Coronary bypass surgery
       Heart failure is not covered
   Rehab Options at UIC and IL
   Conclusions
           Cardiac Rehab Safety
   Supervision: Important consideration when
    prescribing an exercise
     Patients at moderate or high risk (Class C) should
      participate in a medically supervised program with
      ECG monitoring and personnel and equipment
      suitable for advanced cardiac life support.
     This level of supervision should be continued for 8
      to 12 weeks until the safety of the prescribed
      exercise regimen has been established
          Cardiac Rehab Safety
   Exercise in Class B and C patients is
    associated with a small risk of adverse
    events.
   The 2007 American Heart Association
    scientific statement on exercise the acute
    cardiovascular event rate estimated at one
    event in 60,000 to 80,000 hours of supervised
    exercise (cardiac arrest, death or MI).
           Cardiac Rehab Safety
   Mortality rate in these setting is 1 per 784,000
    patient-hours.
   Non fatal MI rate was 1 per 294,000 patients-
    hours
                            Overview
   What is cardiac rehab
       Components, Terminology & Contraindication
       Safety
   Medicare Coverage
   Evidence
       STEMI UA/NSTEMI
       Stable angina
       Percutaneous coronary intervention
       Coronary bypass surgery
       Heart failure is not covered
   Rehab Options at UIC and IL
   Conclusions
             Medicare Coverage
   March 2006 Medicare expanded coverage of CR
    to include
     Heart valve repair/replacement
     Percutaneous transluminal coronary angioplasty or
      stenting
     Heart or heart lung transplant

   Also extended the time frame of performing the
    services to 36 sessions (generally 2-3 sessions
    per week for 12-18 weeks)
            Medicare Coverage
                      COVERED
 Documented diagnosis of acute myocardial
  infarction within the preceding 12 months
 Coronary bypass surgery

 Stable angina

 Heart valve repair/replacement

 Percutaneous coronary intervention

 Heart or heart-lung transplant
                    NOT COVERED
   Heart failure
                            Overview
   What is cardiac rehab
       Components, Terminology & Contraindication
       Safety
   Medicare Coverage
   Evidence
       STEMI UA/NSTEMI
       Stable angina
       Percutaneous coronary intervention
       Coronary bypass surgery
       Heart failure is not covered
   Rehab Options at UIC and IL
   Conclusions
                              Evidence
    STEMI: Class IC
    Cardiac rehabilitation/secondary prevention
     programs, when available, are recommended for
     patients with STEMI, particularly those with
     multiple modifiable risk factors and/or those
     moderate- to high-risk patients in whom
     supervised exercise training is warranted


    New ACC/AHA Guidelines for the Management of Patients with STEMI
    11/2/2004
             Evidence post STEMI
   Meta-analysis (8440 patients) of total mortality for the exercise-
    only intervention demonstrated a reduction in all-cause
    mortality (random effects model OR 0.73 [0.54, 0.98])
    compared with usual care.
   Comprehensive cardiac rehabilitation reduced all-cause mortality
    but to a lesser degree (OR 0.87 [0.71, 1.05]).
   Neither of the interventions had any effect on the occurrence of
    nonfatal MI.



Jolliffe JA, Rees K, Taylor RS, Thompson D, Oldridge N, Ebrahim S. Exercise-
   based rehabilitation for coronary heart disease. Cochrane Database Syst Rev
   2001 CD001800.
          Evidence post STEMI
   Results were of limited reliability because the
    quality of reporting in the studies was generally
    poor, and there were high losses to follow-up
   Individual trials were small.
   Trials were performed in the 1980s and earlier,
    before the contemporary advances in both the
    therapy and secondary prevention of MI
         Updated 2007 UA/NSTEMI
                Guidelines
   NSTEMI: CLASS IB
   Cardiac rehabilitation/secondary prevention programs,
    when available, are recommended for patients with
    UA/NSTEMI, particularly those with multiple
    modifiable risk factors and those moderate- to high-risk
    patients in whom supervised or monitored exercise
    training is warranted.

       ACC/AHA 2007 Guidelines for the Management of Patients
        With Unstable Angina/Non–ST-Elevation Myocardial
        Infarction
         Updated 2007 UA/NSTEMI
                Guidelines
   2005 meta-analysis of 11 trials of 2285 patients with coronary
    disease (most but not all post-MI) who were randomly
    assigned to exercise rehabilitation alone or control therapy.
   Exercise was associated with a significant reduction in all-
    cause mortality (6.2 versus 9.0 percent, summary risk
    ratio 0.72, 95% CI 0.54-0.95).
   There was an almost significant reduction in recurrent MI
    in the exercise group (summary risk ratio 0.76, 95% CI 0.57-
    1.01).


   Meta-analysis: secondary prevention programs for patients with coronary
    artery disease. AU Clark AM; Hartling L; Vandermeer B; McAlister FA SO
    Ann Intern Med 2005 Nov 1;143(9):659-72.
           Updated 2007 UA/NSTEMI
                  Guidelines
   Retrospective study among 1,821 persons from 1982 and 1998, with an
    incident MI hospitalized in Olmsted County
   58% men, 46% age >70 years)
   55% participated in cardiac rehabilitation. Participants had a lower risk of
    death and recurrent MI at three years (p < 0.001 and p = 0.049, respectively).
   The survival benefit associated with participation was stronger in more recent
    years
        RR for 1998 vs. 1982 0.28, 95% CI 0.18 to 0.43;
        RR for 1990 vs. 1982 0.41, 95% CI 0.33 to 0.52).




        Witt BJ, Jacobsen SJ, Weston SA, et al. Cardiac rehabilitation after myocardial
         infarction in the community. J Am Coll Cardiol 2004; 44:988 –96.
   Figure 2 Expected and observed
    survival by participation in cardiac
    rehabilitation. (A) non-participants;
    (B) participants.
                         Overview
   What is cardiac rehab
       Components, Terminology & Contraindication
       Safety
   Medicare Coverage
   Evidence
       STEMI UA/NSTEMI
       Stable angina & Percutaneous coronary intervention
       Coronary bypass surgery
       Heart failure is not covered
   Rehab Options at UIC and IL
   Conclusions
               Stable Angina
   Class IB: Comprehensive cardiac
    rehabilitation program




   ACC/AHA 2002 Guideline Update for the
    Management of Patients With Chronic
    Stable Angina
                   Sable Angina
   Nine randomized trials and four randomized trials have
    examined objective measures of ischemia
   One study used ST-segment depression on ambulatory
    monitoring,
   Three used exercise myocardial perfusion imaging .
   Three of the four studies demonstrated a reduction in
    objective measures of ischemia in those patients
    randomized to the exercise group compared with the
    control group.
                  Following PCI
   Cardiac rehabilitation programs are
    recommended, particularly for those patients
    with multiple modifiable risk factors and/or
    those moderate- to high-risk patients in whom
    supervised exercise training is warranted.

       ACC/AHA/SCAI 2005 Guideline Update for
        Percutaneous Coronary Intervention
                         Overview
   What is cardiac rehab
       Components, Terminology & Contraindication
       Safety
   Medicare Coverage
   Evidence
       STEMI UA/NSTEMI
       Stable angina & Percutaneous coronary intervention
       Coronary bypass surgery
       Heart failure is not covered
   Rehab Options at UIC and IL
   Conclusions
                Rehab & CABG
   Class IB
   Cardiac rehabilitation should be offered to all
    eligible patients after CABG.




   ACC/AHA Coronary Artery Bypass Graft Surgery
    (CABG): Guideline Update for Date: 2004
                                Rehab & CABG
   Cardiac rehabilitation has been shown to reduce
    mortality
   Cardiac rehabilitation beginning 4 to 8 weeks after
    coronary bypass and consisting of 3-times-weekly
    educational and exercise sessions for 3 months is
    associated with a 35% increase in exercise tolerance (P
    equals 0.0001), a slight (2%) but significant (P equals
    0.05) increase in HDL-C, and a 6% reduction in body
    fat (P equals 0.002)

   Milani RV, Lavie CJ. The effects of body composition changes to observed improvements in cardiopulmonary parameters after
    exercise training with cardiac rehabilitation. Chest 1998; 113:599-601
                         Overview
   What is cardiac rehab
       Components, Terminology & Contraindication
       Safety
   Medicare Coverage
   Evidence
       STEMI UA/NSTEMI
       Stable angina & Percutaneous coronary intervention
       Coronary bypass surgery
       Heart failure is not covered
   Rehab Options at UIC and IL
   Conclusions
                Rehab & CHF
   In the 1970s, exercise training of HF patients
    was discouraged due to concerns of worsening
    symptoms.
   Early observations in the 1980s documented
    improvements in exercise function for patients
    with HF with a low rate of complications.
               Rehab & CHF
   ACC/AHA guideline summary:
    Management of patients with current or
    prior symptoms of heart failure (HF) and a
    reduced left ventricular ejection fraction
    (LVEF)
   Class IC- Exercise training as an adjunctive
    approach to improve clinical status in
    ambulatory patients.
                       Rehab & CHF
   Meta-analysis of nine randomized controlled trials including 801 patients (395
    of whom received exercise training compared to 406 controls)
   Exercise training reduces hospitalization and improves survival in patients
    with heart failure.
   Follow up of 705 (729) days there were 88 (22%) deaths in the exercise arm
    and 105 (26%) in the control arm. (hazard ratio 0.65, 95% confidence interval,
    0.46 to 0.92; log rank chi(2) = 5.9; P = 0.015).
   The secondary end point of death or admission to hospital was also reduced
    (0.72, 0.56 to 0.93; log rank chi(2) = 6.4; P = 0.011).




   BMJ 2004 Jan 24;328(7433):189. Epub 2004 Jan 16.

                  Rehab & CHF

   The HF ACTION trial is testing the hypothesis that
    exercise training will reduce the combined end point of
    hospitalization and mortality in patients with NYHA
    class II-IV heart failure
   This trial has completed enrollment and is positioned to
    completion in February of 2008.
   Approximately 1500 patients will participate around the
    country and Canada for an average of four years.
                         Overview
   What is cardiac rehab
       Components, Terminology & Contraindication
       Safety
   Medicare Coverage
   Evidence
       STEMI UA/NSTEMI
       Stable angina & Percutaneous coronary intervention
       Coronary bypass surgery
       Heart failure is not covered
   Rehab Options at UIC and IL
   Conclusions
       Type of Rehab Programs
   Exercise only Cardiac Rehab programs
   Comprehensive Cardiac Rehab programs
UIC has an exercise only cardiac rehab program
 Outpatient PT
 Perform 3 lead EKG monitoring
 Develop training programs
 Willing to work with primary physicians
 Document results in power chart
                      AACVPR
   Founded in 1985, the American Association of
    Cardiovascular and Pulmonary Rehabilitation
   Certify comprehensive rehab programs
   42 Certified programs in IL
       Advocate Christ Medical Center
                         Overview
   What is cardiac rehab
       Components, Terminology & Contraindication
       Safety
   Medicare Coverage
   Evidence
       STEMI UA/NSTEMI
       Stable angina & Percutaneous coronary intervention
       Coronary bypass surgery
       Heart failure is not covered
   Rehab Options at UIC and IL
   Conclusions
      Conclusion: Cardiac Rehab
1.   Vastly underutilized with less than 30% of
     patients participating in CR programs after a
     CV event.
2.   Reasonable evidence of efficacy in various
     patient populations
3.   Covered by Medicare in many populations
4.   UIC does over exercise only programs
5.   Overall this is something I will utilize more of
Cardiac Rehab
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Cardiac Rehab
Dr. S.A. moezzi

				
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