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Chuck Kitchen, MA, FAACVPR
[email protected]
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http://www.cms.gov/medicare-coveragedatabase/details/nca-decisionmemo.aspx?NCAId=270
NCD 20:10
 Effective date: February 18, 2014
 CAG # 00437N
 HF patients are not eligible for ICR
 Evidence of benefit based on CR model, not
ICR
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Same regulation for HF: 42 CFR 410.49
 1-2 hour sessions/day
 > 91 minutes=2 sessions
 < 90 minutes=1 session
 Up to 36 sessions per course
 Up to 36 weeks to complete CR course
 Required components
 Physician-prescribed exercise (CR team)
 Cardiac risk factor reduction interventions
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CMS criteria were derived from HFACTION Trial for patient eligibility.
Research design often differs from “real
world” procedure for valid reasons.
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Beneficiaries with stable, chronic heart failure
meeting ALL of following:
1. Left ventricular ejection fraction < 35%
2. NYHA class II-IV symptoms despite being
on optimal heart failure therapy for at least
6 weeks
3. Stable=have not had recent (< 6 weeks) or
planned (< 6 months) major cardiovascular
hospitalizations or procedures
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Beneficiaries with stable, chronic heart
failure meeting all of following:
1. Left ventricular ejection fraction <
35%
 Measurement by any method is OK
 EF >35% not eligible
▪ EF not always an exact measurement
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Beneficiaries with stable, chronic heart failure
meeting all of following:
2. NYHA class II-IV symptoms despite
being on optimal heart failure therapy
for at least 6 weeks
 Goal for HF patients is not symptom-free,
but that patients are able to monitor and
control their symptoms
 Similar to stable angina
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Beneficiaries with stable, chronic heart failure
meeting all of following:
3. Stable=have not had recent (< 6 weeks)
or planned (< 6 months) major
cardiovascular hospitalizations or
procedures
 Hospitalization is not required
 No per year or per lifetime limit, as with all
CR dx
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30-day all-cause re-admission penalties for
HF dx
 Role for CR to provide transitional
treatment to improve care coordination
▪ Start education earlier post-DC?
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What about patient with AMI who has
EF < 35%?
What about patient who would benefit
from > 36 sessions?
 Similarities to stable angina diagnosis
 Goal is to prepare patient for selfmanagement
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5.1 MILLION people have CHF
825,000 new cases per year
279,000 total mention mortality-2010
57,000 underlying cause 2010
1,084,000 hospital discharges-2005
Estimated cost 2005-34.8 BILLION
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YES!!!
HF-ACTION TRIAL
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There was a small reduction in the combined end-point of all
cause death or all-cause hospitalization. This was the
primary endpoint for the trial and is what is driving some of
the media headlines.
There was a modest reduction in the important protocolspecified disease-specific combined end-point of CV death or
HF hospitalization. Yes, this ~14% reduction is modest, but
please note that this improvement occurred in patients
already receiving (on-top-of) excellent evidence-based
background therapy…. ~92% were on ACE inhibitors or
angiotensin receptor blockers; 95% on beta-blockade; and
40% were enrolled with ICD device already implanted.
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Exercise did not increase the risk for events.
There was a modest improvement in quality of life
scores among the patients in the exercise group.
 Finally, “Based on the safety of exercise training and
the modest reduction in clinical events, the HFACTION study results support a prescribed exercise
training program for patients with reduced LV
function and HF symptoms in addition to evidencebased therapy.”
Steven Keteyian, PhD CEPA
website
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“Cardiac Rehabilitation Exercise and Self-Care for
Chronic Heart Failure”. Ades PA, Keteyian SJ,
Balady GJ, Houston-Miller N, et al. JACC Heart
Fail 2013;1:540-547.
 Evidence to support
 Exercise prescription
 Self-care counseling
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Constant Work Rate (CWR)
 The workload is fixed and remains the same
throughout the exercise session
 Example: Treadmill 3.0mph 2% grade for 20 min
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Interval Training
 The workload varies throughout the exercise
session.
 Example: Treadmill 2.5mph 2% grade for 5 min
increase to 3.0mph 3.5% grade for 5 min, etc
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AIT-Aerobic Interval Training
MCT-Moderate Continuous Training
MICE-Moderate Intensity Aerobic Continuous
Exercise
HIIE-High Intensity Aerobic Interval Exercise
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Exercise Intensity Domains
 Assumes the use of CWR method
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Light to Moderate
Moderate to High
High to Severe
Severe to Extreme
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All work rates with steady state VO2 below
the 1st VT.
Blood lactate does not elevate above resting
levels
Metabolism is aerobic
Generally well tolerated with modest fatigue
Able to maintain for greater than 30-40
minutes
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Work rates between 1st VT and CP
Typically can be sustained for about 30 min
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All work rates above CP
No steady state is achieved
Blood lactate continually rises
Duration less than 20 minutes
Can only be used for interval training, not
continuous
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Work rate is so high that fatigue comes
before peak VO2 can be reached
Less than 3 minutes duration
As a result of short duration blood lactate
levels not as high as with High to Severe
intensity
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Intervals-Green Arrows
100
90
80
Warm-up
60-70%
8-10
minutes
85-95%
4 minutes
70
60
50
40
30
20
10
0
Cool-down
60-70%
3-5 minutes
Active Recovery-Blue
60-70%
3 minutes
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40
35
30
*
25
20
15
10
5
0
CAD
CHF
*
Baseline
AIT
End
Baseline
End
MCT
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Meta analysis, over 5800 patients
High intensity, vigorous intensity, moderate
intensity, low intensity groups
Peak VO2 increased 23% in High intensity vs
control
Vigorous and moderate intensity also showed
significant improvement
Low intensity did not show improvement
▪ Ismail H, McFarlane JR, Nojoumian AH, et al. “Clinical Outcomes and
Cardiovascular Responses to Different Exercise Training Intensities in
Patients with Heart Failure” JACC Heart Fail 2013; 1(6): 515-522
Ismail H, McFarlane JR, Nojoumian AH, et al. “Clinical Outcomes
and Cardiovascular Responses to Different Exercise Training
Intensities in Patients with Heart Failure” JACC Heart Fail 2013; 1(6):
515-522
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Higher intensity groups increased VO2 the
most
Higher peak VO2 equals lower mortality
NO DEATHS with over 123,000 patient hours
of exercise training!!
Higher intensity exercise is safe and effective
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Women showed similar increases in peak VO2
as men
However, women had larger decrease in
hospitalization and larger reduction in all
cause mortality.
▪ Pina IL, Bittner V, Clare RM, et al. “Effects of Exercise Training on
Outcomes in Women with Heart Failure: Analysis of HF-ACTION
by Sex” JACC Heart Fail Published online February 26, 2014.
F.I.T.T. PRINCIPLE
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Frequency
Intensity
Time
Type
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FREQUENCY
3 Days per week initially
Build up to 4-5 days per week
INTENSITY
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RPE Scale
Dyspnea
Heart Rate
6
7 very, very light
8
9 very light
10
INTENSITY
RPE SCALE
11 light
12
13 somewhat hard
14
15 hard
16
17 very hard
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19 very, very hard
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INTENSITY
DYSPNEA SCALE (Modified Borg)
0
None
5 Severe
0.5 Very, Very slight
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1
Very slight
7 Very Severe
2
Slight
8
3
Moderate
9 Very, Very Severe
4
Somewhat severe
10 Maximum
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INTENSITY
HEART RATE
40% to 85% of HR reserve method
Start slowly and progress slowly
Progress to 60 to 85% of HR reserve
Beware of failure of HR to rise appropriately!
With increased HR’s use interval training
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TIME
Initially 10 to 20 minutes
20 to 40 minutes/session
May have to use shorter bouts (2-6 mins)
more frequently with 2 to 4 minute rest
periods
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TYPE
Aerobic Interval Training
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Exercise Prescription is an Art!!
Every patient is different
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Ades PA, Keteyian SJ, Balady GJ, Houston-Miller N, et al.
“Cardiac Rehabilitation Exercise and Self-Care for Chronic
Heart Failure” JACC Heart Fail 2013;1(6): 540-547
Go AS, Mozaffarian D, Roger VL, et al. “Heart Disease and
Stroke Statistics 2014 Update: A Report From the American;
Heart Association” Circulation 2014 129: e28-e292
Ismail H, McFarlane JR, Nojoumian AH, et al. “Clinical
Outcomes and Cardiovascular Responses to Different
Exercise Training Intensities in Patients with Heart Failure”
JACC Heart Fail 2013; 1(6): 515-522
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Mezzani, A, Hamm, LF, Jones AM, et al. Aerobic Exercise Intensity
Assessment and Prescription in Cardiac Rehabilitation: A Joint
Position Statement of the European Association for Cardiovascular
Prevention and Rehabilitation, The American Association of
Cardiovascular and Pulmonary Rehabilitation, and the Canadian
Association of Cardiac Rehabilitation. JCRP 2012; 32(6): 327-350
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O’Connor CM, Whellan DJ, Lee KL, et al. “Efficacy and Safety of
Exercise Training in Patients with Chronic Heart Failure: HFACTION Randomized Controlled Trial” JAMA 2009; 301(14): 14391450
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Pina IL, Bittner V, Clare RM, et al. “Effects of Exercise Training on
Outcomes in Women with Heart Failure: Analysis of HF-ACTION
by Sex” JACC Heart Fail Published online February 26, 2014.