Cardiac Rehabilitation November 1 st, 2007 Jeffrey Marogil, MD UIC Cardiology

Cardiac Cardiac RehabilitationRehabilitationNovember 1November 1stst, ,

20072007Jeffrey Marogil, MDJeffrey Marogil, MD

UIC CardiologyUIC Cardiology

Up until the 1950s, strict bed rest Up until the 1950s, strict bed rest was thought to be the best medicine was thought to be the best medicine after a heart attack. after a heart attack.

Following discharge moderately Following discharge moderately stressful activity such as climbing stressful activity such as climbing stairs was discouraged stairs was discouraged for a year or for a year or more.more.

IntroductionIntroduction


"The patient is to be guarded by day "The patient is to be guarded by day and night nursing and helped in and night nursing and helped in every way to avoid voluntary every way to avoid voluntary movement or effort." movement or effort."

Thomas Lewis, 1933Thomas Lewis, 1933


Despite the known benefits of Despite the known benefits of cardiac rehabilitation (CR) and cardiac rehabilitation (CR) and widespread endorsement (CR) is widespread endorsement (CR) is vastly underutilized and less than vastly underutilized and less than 30% of patients participate in CR 30% of patients participate in CR programs after a CV event.programs after a CV event.

OverviewOverview What is cardiac rehabWhat is cardiac rehab

Components, Terminology & ContraindicationComponents, Terminology & Contraindication SafetySafety

Medicare CoverageMedicare Coverage EvidenceEvidence

STEMI UA/NSTEMISTEMI UA/NSTEMI Stable angina & Percutaneous coronary

intervention Coronary bypass surgery Heart failure

Rehab Options at UIC and in IL Conclusions

What is Cardiac Rehab?What is Cardiac Rehab?

Definition:Definition: Cardiac rehabilitations services are Cardiac rehabilitations services are

comprehensive, long-term programs comprehensive, long-term programs involving involving medical evaluation, medical evaluation, prescribed exercise, prescribed exercise, cardiac risk factor modification, cardiac risk factor modification, educations and counseling. educations and counseling.

These programs are designed to limit theThese programs are designed to limit the physiologic and psychological effects of cardiac illness, physiologic and psychological effects of cardiac illness, reduce the risk for sudden death or reinfacrction, reduce the risk for sudden death or reinfacrction, control cardiac symptoms, stabilize or reverse the control cardiac symptoms, stabilize or reverse the

atherosclerotic process, atherosclerotic process, and enhance the psychosocial and vocational status of and enhance the psychosocial and vocational status of

selected patientsselected patients

2007 American Association of 2007 American Association of Cardiovascular and Pulmonary Cardiovascular and Pulmonary Rehabilitation/AHA/ACC GuidelinesRehabilitation/AHA/ACC Guidelines

Performance Measures on Cardiac Rehabilitation for Performance Measures on Cardiac Rehabilitation for Referral to and Delivery of Cardiac Referral to and Delivery of Cardiac Rehabilitation/Secondary Prevention Services: Rehabilitation/Secondary Prevention Services:

J Am Coll Cardiol 2007;50:1400-33 J Am Coll Cardiol 2007;50:1400-33

Cardiac Rehab Cardiac Rehab TerminologyTerminology

Phase 1: Inpatient Rehab - A program that Phase 1: Inpatient Rehab - A program that delivers preventive and rehabilitative delivers preventive and rehabilitative services to hospitalized patients following services to hospitalized patients following an index CVD eventan index CVD event

Phase II: Early outpatient CR - a Phase II: Early outpatient CR - a programmed that delivers preventive and programmed that delivers preventive and rehabilitative services to patients in the rehabilitative services to patients in the outpatient setting early after CVD event outpatient setting early after CVD event within the first 3-6 months and continuing within the first 3-6 months and continuing for up to 1 yearfor up to 1 year

Phase III: Long-term outpatient CR - Longer Phase III: Long-term outpatient CR - Longer term delivery or preventive and rehabterm delivery or preventive and rehab

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



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.



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.


Absolute Contraindication Absolute Contraindication to Exerciseto 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 Relative Contraindication to Exerciseto 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;

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 RehabCardiac 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 RateMaximum 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 Cardiac Rehab Exercise IntensityIntensity

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 RehabCardiac 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.


One MET is defined as 3.5 mL O2 uptake/kg per min, which is the resting oxygen uptake in a sitting position.

Extra Marital sex




STEMI UA/NSTEMISTEMI UA/NSTEMI Stable angina Percutaneous coronary intervention Coronary bypass surgery Heart failure is not covered

Rehab Options at UIC and IL Conclusions

Cardiac Rehab SafetyCardiac 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


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).


Mortality rate in these setting is 1 Mortality rate in these setting is 1 per 784,000 patient-hours.per 784,000 patient-hours.

Non fatal MI rate was 1 per 294,000 Non fatal MI rate was 1 per 294,000 patients-hourspatients-hours






March 2006 Medicare expanded March 2006 Medicare expanded coverage of CR to includecoverage of CR to include Heart valve repair/replacementHeart valve repair/replacement Percutaneous transluminal coronary Percutaneous transluminal coronary

angioplasty or stentingangioplasty or stenting Heart or heart lung transplantHeart or heart lung transplant

Also extended the time frame of Also extended the time frame of performing the services to 36 performing the services to 36 sessions (generally 2-3 sessions per sessions (generally 2-3 sessions per week for 12-18 weeks)week for 12-18 weeks)

Medicare CoverageMedicare Coverage

Medicare CoverageMedicare CoverageCOVERED

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






New ACC/AHA Guidelines for the Management of Patients with STEMI11/2/2004

STEMI: Class ICSTEMI: Class IC Cardiac rehabilitation/secondary Cardiac rehabilitation/secondary

prevention programs, when prevention programs, when available, are recommended for available, are recommended for patients with STEMI, particularly patients with STEMI, particularly those with multiple modifiable risk those with multiple modifiable risk factors and/or those moderate- to factors and/or those moderate- to high-risk patients in whom high-risk patients in whom supervised exercise training is supervised exercise training is warrantedwarranted

EvidenceEvidence

Evidence post STEMIEvidence 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 STEMIEvidence 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. Individual trials were small. Trials were performed in the 1980s Trials were performed in the 1980s

and earlier, before the contemporary and earlier, before the contemporary advances in both the therapy and advances in both the therapy and secondary prevention of MIsecondary prevention of MI

Updated 2007 UA/NSTEMI Updated 2007 UA/NSTEMI GuidelinesGuidelines

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


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.


Retrospective study among 1,821 persons from 1982 and 1982 and 1998, with an incident MI hospitalized in Olmsted County1998, 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 Figure 2 Expected and observed survival by participation in survival by participation in cardiac rehabilitation. cardiac rehabilitation. (A)(A) non- non-

participants; participants; (B)(B) participants. participants.





intervention Coronary bypass surgery Heart failure is not covered


Stable AnginaStable Angina

Class IB: Comprehensive cardiac rehabilitation program

ACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina

Sable AnginaSable 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.

Stable AnginaStable Angina

Following PCIFollowing 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







Rehab & CABGRehab & 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 & CABGRehab & 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







Rehab & CHFRehab & CHF

In the 1970s, exercise training of HF In the 1970s, exercise training of HF patients was discouraged due to patients was discouraged due to concerns of worsening symptoms. concerns of worsening symptoms.

Early observations in the 1980s Early observations in the 1980s documented improvements in documented improvements in exercise function for patients with exercise function for patients with HF with a low rate of complications. HF with a low rate of complications.


ACC/AHA guideline summary: ACC/AHA guideline summary: Management of patients with Management of patients with current or prior symptoms of heart current or prior symptoms of heart failure (HF) and a reduced left failure (HF) and a reduced left ventricular ejection fraction (LVEF)ventricular ejection fraction (LVEF)

Class IC- Class IC- Exercise training as an Exercise training as an adjunctive approach to improve clinical adjunctive approach to improve clinical status in ambulatory patients. status in ambulatory patients.

Rehab & CHFRehab & CHF Meta-analysis of nine randomized controlled trials including Meta-analysis of nine randomized controlled trials including

801 patients (395 of whom received exercise training 801 patients (395 of whom received exercise training compared to 406 controls)compared to 406 controls)

Exercise training reduces hospitalization and improves survival Exercise training reduces hospitalization and improves survival in patients with heart failure. 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.


The HF ACTION trial is testing the hypothesis The HF ACTION trial is testing the hypothesis

that exercise training will reduce the that exercise training will reduce the combined end point of hospitalization and combined end point of hospitalization and mortality in patients with NYHA class II-IV mortality in patients with NYHA class II-IV heart failure heart failure

This trial has completed enrollment and is This trial has completed enrollment and is positioned to completion in February of 2008.positioned to completion in February of 2008.

Approximately 1500 patients will participate Approximately 1500 patients will participate around the country and Canada for an around the country and Canada for an average of four years. average of four years.







Type of Rehab ProgramsType of Rehab Programs

Exercise only Cardiac Rehab Exercise only Cardiac Rehab programsprograms

Comprehensive Cardiac Rehab Comprehensive Cardiac Rehab programsprograms

UIC has an exercise only cardiac UIC has an exercise only cardiac rehab program Outpatient PTrehab program Outpatient PT

Perform 3 lead EKG monitoringPerform 3 lead EKG monitoring

Develop training programsDevelop training programs

Willing to work with primary Willing to work with primary physicians physicians

Document results in power chartDocument results in power chart

AACVPRAACVPR

Founded in 1985, the American Founded in 1985, the American Association of Cardiovascular and Association of Cardiovascular and Pulmonary Rehabilitation Pulmonary Rehabilitation

Certify comprehensive rehab Certify comprehensive rehab programsprograms

42 Certified programs in IL42 Certified programs in IL Advocate Christ Medical CenterAdvocate Christ Medical Center







Conclusion: Cardiac Conclusion: Cardiac RehabRehab

1.1. Vastly underutilized with less than 30% Vastly underutilized with less than 30% of patients participating in CR programs of patients participating in CR programs after a CV event.after a CV event.

2.2. Reasonable evidence of efficacy in Reasonable evidence of efficacy in various patient populationsvarious patient populations

3.3. Covered by Medicare in many Covered by Medicare in many populationspopulations

4.4. UIC does over exercise only programsUIC does over exercise only programs

5.5. Overall this is something I will utilize Overall this is something I will utilize more ofmore of

Documents

Cardiac Rehabilitation November 1 st, 2007 Jeffrey Marogil, MD UIC Cardiology