Cardiac Rehabilitation and Secondary Prevention...–HD and Risk factors –Dietician – healthy diet –Stress Mx –Adjustment and recovery • CR is part of usual care • Encourage

Cardiac Rehabilitation and

Secondary Prevention

©2018 National Heart Foundation of Australia

Heart Foundation - What do we do?

• Leading charity aiming to reduce death

and disability from coronary heart

disease.

• Produce information for the community

and health professionals.

• Work with decision makers to improve

services.

• Through donations, fund leading

research in Australia.


Cardiovascular Disease


• On average one Australian dies as a result of CVD every 12 mintues.1

• CVD has the highest level of health-care expenditure of any disease

group. Between 2000-01 and 2008-09, health-care expenditure

allocated to CVD increased by 48% from $5,207 million to $7,717

million, representing 12% of the total expenditure budget.

1. Australian Bureau of Statistics. Causes of Death 2013 (3303.0). March 2015.

2. Australian Institute of Health and Welfare 2014. Health-care expenditure on cardiovascular diseases 2008-2009. Cat no.

CVD 65. Canberra: AIHW.

Cardiovascular Disease in Australia

• Around half of all coronary events occur in those people who

have had a prior event

• People with existing CHD

– Have an increased risk of sudden death

– Have an increased risk of developing Chronic Heart

Failure

1. Australian Bureau of Statistics. Causes of

Death 2009 (3303.0). May 2011


What is Cardiac / Cardiovascular Rehabilitation

and Secondary Prevention?


▪ “all measures used to help people with heart disease return to an active and

satisfying life and to prevent the recurrence of cardiac events”

▪ “…..it involves medical care, control of biomedical and behavioural risk

factors, psychosocial care, education and support for self-management”

▪ These are all similar terms which are often interchanged.

▪ Cardiac Rehabilitation is often time-limited, a component of the Secondary

Prevention continuum that is lifelong.

It doesn’t matter so much what you call it as long as the patient gets referred to it!


Cardiac Rehabilitation

• reduces mortality

• accelerates recovery

• improves clinical outcomes (improved chol, BP)

• improves behavioural outcomes (ex tolerance, smoking cessation)

• reduces repeat cardiovascular events and hospital readmissions

• strengthens adherence to medication and enhances mental health

and QoL

Briffa T et al. An integrated and coordinated approach to preventing disease events in Australia.

Policy statement from the Australian Cardiovascular Health and Rehabilitation Association, 2009.

Med J Aust:190:683-6.

The evidence

• Systematic reviews

– Heran et al (2011) - improved overall and CV mortality, hospital

readmission rates, QoL

– Anderson et al. (2016) exercise based CR significantly reduced

hospital admission and cardiovascular mortality

– van Halewijn et al. (2017) found no effect on all-cause mortality,

but reduction in CV mortality by 58%. (2010-2015)

– Powell et al. (2018) re-examined the evidence yr 2000 onwards -

no sig difference in all- cause or CV mortality and only borderline

statistical difference in hospital admissions

The evidence

• RCT

– West et al. 2011- trial of 1813 patients in the UK no significant

differences in mortality, cardiac events or level of PA.

• Cohort

– reduced all-cause mortality and hospital re-ad rates following CR

widely reported in large population studies (de Vries et al. 2015;

Dunlay et al. 2014; Pouche et al. 2016; Kureshi, 2016; Goel;2018,

Lee, 2016; Junger et al, 2010; Hammil et al. 2010; Jimmenez-

Navarro et al. 2017).

Different approaches to CR

• To address poor participation and access.

• Reviews - positive outcomes for telephone support, video

conferencing, home based programs, or internet based

programs.

– Clark et al., 2015; Dalal et al. 2010; Huang et al., 2015; Kotb et al.,

2014.

• RCT’s demonstrating similar benefits of alternative models of

CR.

– Jolly et al., 2009; Varnfield et al., 2014; Cossette et al., 2012.

Lack of referrals to CR

1. NHS Improvement Heart. Making the case for cardiac rehabilitation: modelling potential impact on readmissions, 2013.

2. Heart Foundation. Heart Attack Survivor Survey, 2015.

Only about 30% of patients

are referred to cardiac

rehabilitation1.

65% is the gold standard

target set by the UK

National Health Service

which meets international

best practice1

71% of patients would go to

cardiac rehabilitation if a

health professional

discussed it with them

before leaving hospital 2

• 27% acute coronary syndrome patients received optimal in-hospital preventive care.

• ‘Optimal care’ means receiving lifestyle advice, referral to rehabilitation and

prescription of secondary prevention drugs.

• STEMI, NSTEMI, PCI/CABG during admission or history of hypertension were more

likely to receive optimal preventive care.

• Older patients (>70yrs) or admitted to private hospital = less likely to receive

optimal care.

Redfern J, Hyun K, Chew DP, Astley C, Chow C, Aliprandi-Costa B, Howell T, Carr B, Lintern K, Ranasinghe I, Nallaiah K, Turnbull F, Ferry C, Hammett C, Ellis CJ, French J,

Brieger D and Briffa T. Heart 2014;01-8.

Australian evidence:

Costs

• Of the 54,000 heart attacks that occur each year, each

one costs around $30,000 in healthcare

• Cardiac rehabilitation program costs the health system an

average $885 per person to attend.

De Gruyter, Elaine., Ford, G., Stavreski B. (2016). Economic and Social Impact of Increasing Uptake of Cardiac Rehabilitation

Services – A Cost Benefit Analysis. Heart, Lung and Circulation, 25, 175–183, http://dx.doi.org/10.1016/j.hlc.2015.08.007

http://dx.doi.org/10.1016/j.hlc.2015.08.007

Cost benefits in WA

• If attendance rates increased from 30% to 65 the benefits in

WA after 5 years would be:

– $28.4 million in savings in healthcare costs

– $48 million in social and economic benefits

– Reduction in 1,700 hospital admissions for heart attacks.

De Gruyter, Elaine., Ford, G., Stavreski B. (2016). Economic and Social Impact of Increasing Uptake of Cardiac Rehabilitation

Services – A Cost Benefit Analysis. Heart, Lung and Circulation, 25, 175–183, http://dx.doi.org/10.1016/j.hlc.2015.08.007

http://dx.doi.org/10.1016/j.hlc.2015.08.007

What does Cardiac Rehab involve?

• Traditional programs

– Centre based – multi disciplinary team

– Exercise groups x2/wk for 6-8/52

– Individual support

– Group education sessions

– Medications

– Symptom Mx

– HD and Risk factors

– Dietician – healthy diet

– Stress Mx

– Adjustment and recovery

• CR is part of usual care

• Encourage self management

• Patient may not show interest until weeks, months, years

after initial event



• Alternative models of CR

– Telephone coaching or follow-up

– Internet / phone app based programs

– Telehealth

– Case management / modular approach

– Home based programs

Who’s responsibility is CR and SP?

• Everyone!

• Hospital

– Tertiary

– Secondary

• Primary Care

– GP

– Practice Nurses

– Allied Health

• Community support

– Walking groups

– Local pharmacist

• Private practitioners

– Psychologist

– Physiotherapist

– Dietician

– Diabetes educator

Where ever you work you have the opportunity to help start the ball rolling on

the journey of recovery and lifestyle change.

Teaching on the run

• Opportunistic education

• Engaging the family

• Use different approaches and resources

• Repeating messages in different ways

• Brief intervention motivational interviewing

What policy do we have?

http://www.healthnetworks.h

ealth.wa.gov.au/docs/1405_

CRSP_Pathway_Principles

_WA.pdf

http://www.healthnetworks.health.wa.gov.au/docs/1405_CRSP_Pathway_Principles_WA.pdf

































CRSP Pathway

Principles

CR can occur in

many different

settings

©2018 National Heart F

oundation of Australia



https://www.heartfoundation.org.au/images/uploads/publi

cations/HF.Cardiac_Rehab_Factsheet_WEBHR.pdf

https://www.heartfoundation.org.au/images/uploads/publications/HF.Cardiac_Rehab_Factsheet_WEBHR.pdf































http://www.acra.net.au/why-cardiac-

rehabilitation-really-matters/

ACRA-WA

• Peak body

• Networking • http://www.acra.net.au/

http://www.acra.net.au/why-cardiac-rehabilitation-really-matters/










http://www.acra.net.au/












https://www.heartfoundation.

org.au/cardiac-services-

directory


https://www.heartfoundation.org.au/cardiac-services-directory







Practical

resources



www.heartonline.org.au

The “go to” resource

http://www.heartonline.org.au/









Tips on how to communicate with patients inc difficult topics eg SEX

plus practical resources and tools





Online modules

MHML allow approx. 4-6hrs

HF 3hrs


Sign up for the Heart Health Network

Newsletter (before next VC!)


Heart Foundation HELPLINE

Qualified Health Professionals: supporting you & your patients

Phone: 13 11 12

Email: [email protected]

mailto:[email protected]


Ordering resources: Website or Heart Foundation Helpline (by email or phone)






CALD & Low literacy

©2018 Nati

onal Heart Foundation of Australia


Guidelines


Range of

CR posters. Please contact us in WA


www.heartfailurematters.org (ESC)

http://www.heartfailurematters.org/



St Vincent's heart health (www.svhhearthealth.com.au)

Includes videos: CR overview, exercise, quitting smoking, RF,

returning to activities, medications

http://www.svhhearthealth.com.au/

www.getontrackchallenge.com.au

Teams track activity, fruit & veg


www.myhealthybalance.com.au

Individual healthy lifestyle program

http://www.getontrackchallenge.com.au/









http://www.myhealthybalance.com.au/


Heart Foundation Walking App:

Prime Minister’s One million steps challenge


C25k Couch to 5km in 9 weeks

Health app (iPhone) Activity, mindfulness, nutrition, sleep


FoodSwitch Bupa, The George Institute

traffic-light’ labelling system or the new Health Star Rating system:

Saltswitch, glutenswitch, fatswitch, sugarswitch

Myfitness Pal Calorie counter and diet tracker,

assesses exercise to determine

needs


My Quitbuddy


Cardihab


• CSIRO & Qu Health

• Cost $$$

• Scientifically validated Digital Cardiac Rehabilitation (DCR)

solution uses smartphone apps and web portals to give

clinicians the ability to deliver more convenient, flexible and

engaging CR services to patients

– Far more likely to participate than those who had to travel to an

outpatient clinic (80% vs 60%).

– More likely to adhere to the rules of the program (94% vs 68%) and

see it through to completion (80% vs 48%).


Heart Maps • https://www.heartfoundation.org.au/for-professionals/heart-maps/australian-heart-maps

https://www.heartfoundation.org.au/for-professionals/heart-maps/australian-heart-maps










• What other useful tools or resources would you recommend?

• Evaluation forms: feedback & future topics please

Thank you

Please contact us at:

9388 3343

[email protected]

[email protected]



Secondary Prevention of Heart Disease, Thursday 9th August

Documents

Cardiac Rehabilitation and Secondary Prevention...–HD and Risk factors –Dietician – healthy diet –Stress Mx –Adjustment and recovery • CR is part of usual care • Encourage