Download What is Cardiac Rehabilitation?

Cardiac Rehabilitation
An Underutilized
Class I Treatment
for Cardiovascular Disease
What is Cardiac Rehabilitation?
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Cardiac rehabilitation is a comprehensive exercise, education, and
behavior modification program designed to improve the physical
and emotional condition of patients with heart disease.
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Prescribed to control symptoms, improve exercise tolerance, and
improve overall quality of life.
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The primary goal of cardiac rehabilitation is to enable the
participant to achieve his/her optimal physical, psychological,
social and vocational functioning through exercise training and
lifestyle change.
Core Components of Cardiac Rehabilitation
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Prescribed exercise to improve cardiovascular fitness without
exceeding safe limits
Education about heart disease along with counseling on ways to
stabilize or reverse heart disease by improving risk factors
– Reduction/Cessation of Smoking
– Lipid Management
– Controlling High Blood Pressure
– Weight Loss/Control
– Improve/Manage Diabetes
– Increasing Physical Activity
Encourage Healthy Eating Habits
Improve Psychological Well Being
ACC/AHA Guideline Recommendations
Referral to Cardiac Rehabilitation
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Class I indication in clinical guidelines for
– Myocardial Infarction
– Percutaneous Coronary Intervention
– Coronary Bypass Grafting
– Chronic stable angina
– Heart failure
– Peripheral arterial disease
– Cardiovascular prevention in women
Evidence Supporting the Guidelines
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Decreases Mortality at up to 5 years Post Participation
Decreases Cardiovascular Events
Improves Modifiable Risk Factors
Improves Adherence with Preventive Medications
Improves Function and Exercise Capacity
Improves Quality of Life
Fosters Lifelong Healthy Behaviors
Cardiac Rehabilitation and Survival in Older
Coronary Patients
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Mortality Benefit of Cardiac Rehabilitation
Methods
– Examined 1-5 year mortality in 601,099 Medicare beneficiaries
hospitalized with diagnoses eligible to participate in cardiac
rehabilitation in 1997
– Used propensity based analysis of 70,040 matched pairs to
compare up to 5 year mortality in those who participated in
cardiac rehabilitation compared to those who did not
– Additionally, analysis was performed on a subgroup
(n=17,298) of high-dose CR users (>25 sessions) and matched
low dose users (1-24 sessions)
Suaya JA, Stason WB, Ades PA, et al. Cardiac Rehabilitation and Survival in Older Coronary Patients.
J. Am. Coll. Cardiol. 2009;54;25-33.
Cardiac Rehabilitation and Survival in Older
Coronary Patients
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Results
– Overall Group (n=601,099)
• Crude Mortality Rate at 5 years: Relative risk reduction 59%
– Propensity Based Matched Pairs (70,040 pairs).
• Mortality at 1 year: users 2.2%; non-users 5.3% (relative risk
reduction 58%)
• Mortality at 5 years: users 16.3%; non-users 24.6% (relative risk
reduction 34%)
– Regression Modeling Mortality Rate at 5 years (adjusting for patient
and hospital characteristics)
• 26% relative risk reduction
– Instrumental Variable Modeling
• Mortality Rate at 5 years: Users 29.8%; Non-users 37.8% (21%
relative risk reduction)
– High Dose versus Low Dose (n=17,298)
• Mortality at 1 year: high dose 1.1%; low dose 2.6% (relative risk
reduction 58%)
• Mortality at 5 years: high dose 14.0%; low dose 17.2% (relative
risk reduction 19%)
Impact of Cardiac Rehabilitation on
Mortality Following PCI
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A retrospective analysis from a prospectively collected registry of
2,395 consecutive patients who underwent PCI in Olmsted County,
Minnesota, from 1994 to 2008
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The association of cardiac rehabilitation with all-cause mortality,
cardiac mortality, myocardial infarction, or revascularization was
assessed
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Follow-up of 6.3 years
– 503 total deaths (199 cardiac)
– 394 total myocardial infarctions
– 755 total revascularization
Geol K, Lennon RJ, Tilbury RT et al, Impact of Cardiac Rehabilitation on Mortality Following PCI.
Circulation. 2011;123:2344-2352.
Impact of Cardiac Rehabilitation on
Mortality Following PCI
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Participation in CR (40% (964 of 2395) of the cohort) was
associated with
– a significant decrease in all-cause mortality (hazard ratio, 0.53
to 0.55; P<0.001).
– A trend toward decreased cardiac mortality was also observed
in CR participants;
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No effect was observed for subsequent myocardial infarction or
revascularization.
Geol K, Lennon RJ, Tilbury RT et al, Impact of Cardiac Rehabilitation on Mortality Following PCI.
Circulation. 2011;123:2344-2352.
Relationship between cardiac rehab & longterm risks of death & MI among elderly
Medicare beneficiaries
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Dose dependent reduction in mortality and recurrent MI after
cardiac rehabilitation
Methods
– 30,161 elderly Medicare patients who attended at least 1
cardiac rehabilitation session between January 1, 2000, and
December 31, 2005.
– Used a Cox proportional hazards model to estimate the
relationship between the number of sessions attended and
death and myocardial infarction (MI) at 4 years.
– The cumulative number of sessions was a time-dependent
covariate.
Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship Between Cardiac Rehabilitation and Long-Term Risks
of Death and Myocardial Infarction Among Elderly Medicare Beneficiaries. Circulation. 121(2010); pp 63-70.
Relationship between cardiac rehab & longterm risks of death & MI among elderly
Medicare beneficiaries
• Results
– After adjustment for demographic characteristics, comorbid
conditions, and subsequent hospitalization, patients who
attended 36 sessions had a
• 14% lower risk of death (hazard ratio [HR], 0.86; 95%
confidence interval [CI], 0.77 to 0.97) and a 12% lower
risk of MI (HR, 0.88; 95% CI, 0.83 to 0.93) than those
who attended 24 sessions
• 22% lower risk of death (HR, 0.78; 95% CI, 0.71 to 0.87)
and a 23% lower risk of MI (HR, 0.77; 95% CI, 0.69 to
0.87) than those who attended 12 sessions
• 47% lower risk of death (HR, 0.53; 95% CI, 0.48 to 0.59)
and a 31% lower risk of MI (HR, 0.69; 95% CI, 0.58 to
0.81) than those who attended 1 session
Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship Between Cardiac Rehabilitation and Long-Term Risks
of Death and Myocardial Infarction Among Elderly Medicare Beneficiaries. Circulation. 121(2010); pp 63-70.
Relationship between cardiac rehab & long-term
risks of death & MI among elderly Medicare
beneficiaries
• Among Medicare beneficiaries, a strong dose-response
relationship existed between the number of cardiac
rehabilitation sessions and long-term outcomes.
• Attending all 36 sessions reimbursed by Medicare was
associated with lower risks of death and MI at 4 years
compared with attending fewer sessions.
Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship Between Cardiac Rehabilitation and Long-Term Risks
of Death and Myocardial Infarction Among Elderly Medicare Beneficiaries. Circulation. 121(2010); pp 63-70.
Additional Studies Showing Reduction in
Cardiac Endpoints after Cardiac Rehab
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Cochrane Database on Exercise-Based Rehabilitation for Coronary
Artery Disease: Joliffe JA, Rees K, Taylor RS, et al. 2001;1:CD00180
– Total mortality decreased by 13% to 27%
Taylor RS, Brown A, Ebrahim S, et al. Am J Med 2004;116:682-92
– Exercise based rehab was associated with lower all-cause (OR
0.80) and cardiac mortality (OR 0.74)
– Also lowered lipids, systolic blood pressure, smoking, QOL
Clark AM, Hartling L, Vandermeet B. et al. Meta-analysis: secondary
prevention programs for patients with coronary artery disease. Ann
Intern Med 2005;143:659-72
– Reduced recurrent MI by 17%, 47% mortality benefit at 2 years
Agency for Healthcare Research and Quality (AHRQ) Technology
Assessment Program. Randomized trials of secondary prevention
programs in coronary artery disease: a systematic review. Rockville,
MD: AHRQ, 2005
– Decreased hospitalizations, recurrent MI, and mortality
Despite Evidence Showing Benefit,
Cardiac Rehabilitation is Underutilized
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Of eligible patients, only 14-35% of heart attack survivors and
approximately 31% of patients after CABG participate in cardiac
rehabilitation
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Participation is lowest in women, minorities, socio-economically
disadvantaged patients, and the elderly
JA Suaya, DS Shepard, ST Normand, PA. Ades, J Prottas, WB Stason. Use of Cardiac Rehabilitation
by Medicare Beneficiaries After Myocardial Infarction or Coronary Bypass Surgery. Circulation 2007;116;1653-1662
Healthcare Team Interventions to Improve
Participation in Cardiac Rehabilitation
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Use of quality improvement processes that incorporate the Referral
to Cardiac Rehabilitation Performance Measures
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Facilitated referral processes to encourage participation
–Include referral to cardiac rehab in discharge orders
–Endorsement of benefit to patients by providers
–Mended Hearts chapters provide peer endorsement
–Provision of sufficient information to patient and cardiac
rehabilitation program to allow enrollment
For More Information About Cardiac
Rehabilitation: www.aacpvr.com
References
Core Components of Cardiac Rehabilitation
Balady GJ, Williams MA, Ades PA, et al. Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: 2007 Update: A
Scientific Statement from the American Heart Association and AACVPR. Journal of Cardiopulmonary Rehabilitation and
Prevention. 2007;27:121-129.
Class I indication in Clinical Guidelines
E.M. Antman, D.T. Anbe, P.W. Armstrong et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial
infarction: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines (Committee to Revise the 1999 Guidelines on the Management of Patients with Acute Myocardial Infarction).
J Am Coll Cardiol, 44 (2004), pp. 671–719.
.L. Anderson, C.D. Adams, E.M. Antman et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non–STelevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on
Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable
Angina/Non-ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians,
American College of Physicians, Society for Academic Emergency Medicine, Society for Cardiovascular Angiography and
Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol, 50 (2007), pp. e1–e157.
R.J. Gibbons, J. Abrams, K. Chatterjee et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable
angina—summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines (Committee on the Management of Patients with Chronic Stable Angina). J Am Coll Cardiol, 14 (2003), pp. 159–168.
GN Levine, ER Bates, JC Blackenship et al. ACCF/AHA/SCAI Guideline for Percutaneous Intervention. J Am Coll Cardiol, 24 (2011),
pp.44-122.
LD Hillis, PK Smith, JL Anderson et al. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: executive summary: a
report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am
Coll Cardiol, 124(2011), pp.123-210.
References
S.A. Hunt, W.T. Abraham, M.H. Chin et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure
in the adult—summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll
Cardiol, 46 (2005), pp. 1116–1143.
A.T. Hirsch, Z.J. Haskal, N.R. Hertzer et al. ACC/AHA guidelines for the management of patients with peripheral arterial disease (lower
extremity, renal, mesenteric, and abdominal aortic): executive summary: a collaborative report from the American Association for
Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular
Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing
Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease). J Am Coll Cardiol, 47 (2006),
pp. 1239–1312.
L. Mosca, E.J. Benjamin, K. Berra, Effectiveness-based guidelines for the prevention of cardiovascular disease in women 2011 Update:
a guideline from the American Heart Association. J Am Coll Cardiol, 57 (2011), pp. 1404-1423.
Evidence Supporting the Guidelines
N.K. Wenger. Current Status of Cardiac Rehabilitation. Journal of the American College of Cardiology. 51(2008), pp. 1619–1631.
Cardiac Rehabilitation and Survival in Older Coronary Patients
Suaya JA, Stason WB, Ades PA, et al. Cardiac Rehabilitation and Survival in Older Coronary Patients. J. Am. Coll. Cardiol. 2009;54;2533.
Impact of Cardiac Rehabilitation on Mortality Following PCI
Geol K, Lennon RJ, Tilbury RT et al, Impact of Cardiac Rehabilitation on Mortality Following Percutaneous Coronary Intervention.
Circulation. 2011;123:2344-2352.
References
Relationship between cardiac rehab & long-term risks of death & MI among elderly Medicare beneficiaries
Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship Between Cardiac Rehabilitation and Long-Term Risks of Death and
Myocardial Infarction Among Elderly Medicare Beneficiaries. Circulation. 121(2010); pp 63-70.
Additional Studies Showing Reduction in Cardiac Endpoints after Cardiac Rehab
Cochrane Database on Exercise-Based Rehabilitation for Coronary Artery Disease: Joliffe JA, Rees K, Taylor RS, et al.
2001;1:CD00180
Taylor RS, Brown A, Ebrahim S, et al. Am J Med 2004;116:682-92
Clark AM, Hartling L, Vandermeet B. et al. Meta-analysis: secondary prevention programs for patients with coronary artery disease. Ann
Intern Med 2005;143:659-72
Agency for Healthcare Research and Quality (AHRQ) Technology Assessment Program. Randomized trials of secondary prevention
programs in coronary artery disease: a systematic review. Rockville, MD: AHRQ, 2005
Despite Evidence Showing Benefit, Cardiac Rehabilitation is Underutilized
JA Suaya, DS Shepard, ST Normand, PA. Ades, J Prottas, WB Stason. Use of Cardiac Rehabilitation by Medicare Beneficiaries After
Myocardial Infarction or Coronary Bypass Surgery. Circulation 2007;116;1653-1662
Healthcare Team Interventions to Improve Participation in Cardiac Rehabilitation
Thomas RJ, King M, Lui K, et al. AACVPR/ACCF/AHA 2010 update: performance measures on cardiac rehabilitation referral to cardiac
rehabilitation/secondary prevention services. Circulation. 2010;122:1342-1350.
Balady GJ, Ades PA, Bittner VA et al. Referral, Enrollment, and Delivery of Cardiac Rehabilitation/Secondary Prevention Programs at
Clinical Centers and Beyond: A Presidential Advisory from the American Heart Association. Circulation. 2011.124:2951-60.