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Beneficios de la Rehabilitacion Cardiovascular Marzo 15, 2016 Fundacion Cardiovascular Dr. Jorge Kaplan Meyer Carmen Militza Terzic, MD, PhD Professor and Chair Department of Physical Medicine and Rehabilitation, Co-Director Cardiovascular Rehabilitation Mayo Clinic Rochester, Minnesota, U.S.A. ©2015 MFMER | 3449848-1 2003 Heart Disease Statistics • Worldwide, 17 million people die of CVD/year accounting for 1/3 of global death • In the USA, CVD claimed 40% of all deaths far exceeding all cancer, diabetes, respiratory and infectious diseases combined Rehabilitation and prevention are essential ©2015 MFMER | 3449848-2 Cardiac Rehabilitation Multidisciplinary approach focusing on therapeutic education, individualized exercise training, risk factors management, and optimization of functional status and mental health through regular patient evaluation, monitoring and support of compliance and adherence ©2015 MFMER | 3449848-3 Cardiac Rehabilitation Participants in a cardiac rehabilitation include patients: after an acute coronary syndrome, cardiac surgery (CABG, valve replacement/repair, transplant, ventricular reductions surgery and congenital heart repair, LVAD), patients with compensate congestive heart failure. Gold standard of cardiac care after acute events ©2015 MFMER | 3449848-4 How Does CRP help to control CVD? Healthy lifestyle interventions are a medical necessity that should be prescribed to all individuals. For patients with CVD, the most wellestablished model for healthy lifestyle interventions in the current healthcare model is Cardiac Rehabilitation ©2015 MFMER | 3449848-5 Cardiac Rehabilitation Benefits ©2015 MFMER | 3449848-6 Cardiac Rehabilitation • Improves Symptoms of Exertion • Dyspnea • Fatigue • Claudication • Improves Autonomic tone: increased vagal activity attenuated sympathetic hyperactivity, increase heart rate variability and recovery, reduce resting pulse. • Improves Cardiorespiratory fitness • 10% to 40% increase in aerobic capacity (VO2 peak) • Estimated metabolic equivalents +35% ©2015 MFMER | 3449848-7 Rate of Death Due to CHD by Fitness Level: The Aerobic Center Study Men Women No. of participants Age (y), mean Follow-up (y) 10,224 41.5 8 3120 40.8 8 Cardiopulmonary fitness level Low Moderate High 24.6 7.8 3.1 7.4 2.9 0.8 Rate of death due to CHD per 10,000 person-years. Increased levels of physical activity, exercise training, and overall cardiorespiratory fitness have provided protection in the primary and secondary prevention of CHD Blair et al., JAMA 1989 ©2015 MFMER | 3449848-8 Cardiac Rehabilitation Program: Lipids and Inflammation • Improvement in the blood lipid profile: • Total cholesterol (decrease 7 to 13 mg/d) • LDL (3 to 11 mg/dL) • Triglycerides (-15%) • HDL by 6% (13-16% increase in patients with low HDL-C levels) Greater improvements in patients with very abnormal values ©2015 MFMER | 3449848-9 Median changes in high-sensitive C-reactive protein in control patients with coronary heart disease (CHD) and cardiac rehabilitation patients. Carl J. Lavie et al. Circulation Research. 2015;117:207-219 ©2015 MFMER | 3449848-10 Cardiac Rehabilitation Improvements in CVD Risk Factors Improve Insulin Resistance Lower blood pressure in hypertensive and normal individuals by 6 to 9 mm Hg (systolic and diastolic) Improves metabolic syndrome by 37 % Reduction % fat: -5 ©2015 MFMER | 3449848-11 Cardiac Rehabilitation Program: Weight loss • Promotion of weight loss and weight maintenance 377 patients Mayo Clinic Weight loss (intentional with diet/exercise) associated with reduction mortality and major CVD events ©2015 MFMER | 3449848-12 Cardiac Rehabilitation Program: Psychological Risks Factors May trigger acute CV events High prevalent Psychosocial stress CVD Risk factor Barrier for medical interventions ©2015 MFMER | 3449848-13 Depression is associated with an increased risk for a combination of death or rehospitalization for heart failure, myocardial infarction, or stroke Kaplan-Meier estimated survival in 56,064 patients with or without depression diagnosis before primary isolated CABG from 1997 to 2008 in Sweden. Malin Stenman, Martin J. Holzmann, Ulrik Sartipy The American Journal of Cardiology, Volume 114, Issue 5, 2014 ©2015 MFMER | 3449848-14 Effect of cardiac rehabilitation programs on prevalence of adverse psychological stress parameters (depression, anxiety, and hostility) in younger and older patients with CHD. Carl J. Lavie et al. Circulation Research. 2015;117:207-219 ©2015 MFMER | 3449848-15 • Effect of CR on mortality rates in 139 patients with baseline depression Reduction of mortality by 70% in patients with depression compared with control groups (patients with CVD and no participation in CR) ©2015 MFMER | 3449848-16 Cardiac Rehabilitation Sleep Apnea Screening Independent risk factor for ischemic heart disease and other vascular diseases as well as all cause mortality Hung, Lancet, 1990; Somers, Mayo Clinic Proceedings, 2004 Lopez-Jimenez, Chest, 2008 Dong, Atherosclerosis, 2013 Marshall, J Clin Sleep Med., 2014 Ghazal Atheroscler. 2015 ©2015 MFMER | 3449848-17 Cardiovascular Consequences of OSA Fatal events Non-fatal myocardial infarction, PTCA, stroke Marin, S.J. et al., Lancet, 2005 ©2015 MFMER | 3449848-18 Random-effects meta-analysis of the relationship between obstructive sleep apnea (OSA) and risk of coronary heart disease (CHD). CI = confidence interval; F = female; M = male; RR = relative risk. All combined, OSA was associated with increased risk of developing CHD (RR = 1.37, 0.95–1.98) Jia-Yi Dong, Yong-Hong Zhang, Li-Qiang Qin Atherosclerosis, Volume 229, Issue 2, 2013, 489–495 ©2015 MFMER | 3449848-19 Cardiac Rehabilitation Others benefits Smoking Cessation Assess/intervene/support/follow The strongest predictor of SC at 6 months after PCI was participation in cardiac rehabilitation odds ratio [OR] 3.17, 95% confidence interval [CI] 2.05 to 4.91 p <0.001) Sochor et al., Am J Cardiol. 2015 ©2015 MFMER | 3449848-20 Medication Adherence and CRP Year 1 Year 3 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Statin Aspirin ACEI or ARB Beta Blocker Mayo Case Mayo Clinic Cardiac Rehabilitation Program Outcomes. Squires et al, JCRP 2008;28:180-186 ©2015 MFMER | 3449848-22 Meeting Risk Factor Goals ©2015 MFMER | 3449848-23 Cardiac Rehabilitation: • CVD Hospitalizations • CVD Mortality ©2015 MFMER | 3449848-24 Cardiac Rehabilitation: Impact on Re-admission Rates after MI • Olmsted County, MN • 2991 patients • 1st time MI, 1987-2010 • 52% in CR • CR = ↓ hospitalization • All-cause: ↓ 25% • CV: ↓ 20% • Non-CV: ↓ 28% Similar benefit seen after PCI and CABG Am J Med 2014 ©2015 MFMER | 3449848-25 Mortality After Myocardial Infarction for Cardiac Rehabilitation Participants and Non-Participants Population-based surveillance study of residents discharged from the hospital following their first-ever myocardial infarction in Olmsted County, Minnesota from January 1, 1987 to September 30, 2010 Am J Med. 2014 ©2015 MFMER | 3449848-26 Cardiac Rehabilitation and Mortality Impact in PCI • Mayo Clinic CR-PCI Study • Post PCI patients, 1994-2008 • Cardiac rehabilitation vs no CR • Adjusted Propensity Score Analysis techniques • All-cause mortality 45% lower for CR participants • Mortality benefit began in year one and persisted • Goel et al., 2011 Circulation ©2015 MFMER | 3449848-27 Cardiac Rehabilitation and Mortality Impact in CABG • Mayo Clinic Study • Post CABG 846 patients, 10 years follow up • Cardiac rehabilitation vs no CR • All-cause mortality was reduced by 46% in CR participants Pack et al., 2015 Am. J. Cardiology ©2015 MFMER | 3449848-28 Cardiac Rehabilitation and HF • 1 MET increase is associated with 20%reduction of HF risk • 15 to 17% improvement of peak V02 is associated with reductions in hospitalization (28%) and mortality (35%) ©2015 MFMER | 3449848-29 Cardiac Rehabilitation and HF • HF-ACTION Trial • 30% reduction combined end point of hospitalization and all cause mortality among sub groups that achieved exercise prescription ©2015 MFMER | 3449848-30 Cardiac Rehabilitation Financial issues: cardiac rehabilitation improves prognosis after CVD events in a highly cost effective manner by reducing recurrent hospitalization, health care expenditures while prolonging life IMPROVEMENTS IN OVERALL QUALITY OF LIFE ©2015 MFMER | 3449848-31 Other benefits? ©2015 MFMER | 3449848-32 Enhancing Treatment for Cardiovascular Disease: Exercise and Circulating Angiogenic Cells. Witkowski, et al Exercise & Sport Sciences Reviews. 2011. 2 ©2015 MFMER | 3449848-33 Endurance training increases the number of endothelial progenitor cells in patients with cardiovascular risk and coronary artery disease ©2015 MFMER | 3449848-34 A single exercise bout improves circulating angiogenic cell migration in severe and mild chronic heart failure, restoring it to levels similar to healthy subjects. Van Craenenbroeck et al, European Heart Journal , 2010 ©2015 MFMER | 3449848-35 How Does CRP help to control CVD? - Education about CVD - Improve symptoms CVD - Control cardiovascular risk factors - Promote life style changes - Medication adherence - Decrease mortality, hospitalizations ©2015 MFMER | 3449848-36 Conclusion With this overwhelming scientific evidence supporting the role of cardiac rehabilitation in secondary prevention of CVD: no excuses not to refer patients!!! ©2015 MFMER | 3449848-37 Gracias! ©2015 MFMER | 3449848-38 ©2015 MFMER | 3449848-39 Cardiac Rehabilitation • Improves Endothelium Function • Antithrombotic effect • Peripheral adaptation: skeletal muscles • Decrease arterial stiffness (protection against oxidative stress and inflammation • Enhanced endothelium-dependent vasodilation (arteries, coronary microcirculation) • ©2015 MFMER | 3449848-40 Cardiac Rehabilitation: Benefits • Autonomic Function: • increased vagal activity • attenuated sympathetic hyperactivity • Increased heart rate variability • Increased heart rate recovery • reduced resting pulse ©2015 MFMER | 3449848-41 Cardiac Rehabilitation benefits Smoking Cessation ©2015 MFMER | 3449848-42