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The Cardiology Connection


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The Cardiology Connection

  2. 2. The Problem <ul><li>CAD -- leading cause of death and disability in U.S. among men and women </li></ul><ul><li>Huge numbers: In 1997: </li></ul><ul><ul><li>AMI diagnosis in 1.1 million people </li></ul></ul><ul><ul><li>> 0.8 million revascularization procedures </li></ul></ul><ul><li>Prevention of subsequent events and enhancement of physical function in patients have immense impact </li></ul>
  3. 3. Cardiac Rehabilitation <ul><li>Before the mid-20th C., treatment of MI: </li></ul><ul><ul><li>3 weeks of bedrest </li></ul></ul><ul><ul><li>Out of work up to 6 months, if work was to be permitted </li></ul></ul><ul><ul><li>Little understanding about the pathophysiology, causes, appropriate treatment, and prevention of subsequent events </li></ul></ul><ul><li>Chair therapy: a major and courageous breakthrough! </li></ul>
  4. 4. Cardiac Rehabilitation-2 <ul><li>Programs 1st developed in 1960s </li></ul><ul><li>Benefits of ambulation recognized </li></ul><ul><ul><li>Safer in supervised environment than at home </li></ul></ul><ul><ul><li>Developed into highly structured, physician and nurse-supervised, ECG monitored programs </li></ul></ul><ul><ul><li>Focus primarily on exercise (as medicine) </li></ul></ul><ul><ul><ul><li>Dosage </li></ul></ul></ul><ul><ul><ul><li>Frequency </li></ul></ul></ul><ul><ul><ul><li>Intensity </li></ul></ul></ul>
  5. 5. Cardiac Rehabilitation-3 <ul><li>Hospital stays for MI and ACS 3-5 days </li></ul><ul><ul><li>Reduced deconditioning </li></ul></ul><ul><ul><li>However, reduced opportunity for patient education </li></ul></ul><ul><li>Regular exercise and risk factor modification reduce morbidity and mortality of CHD </li></ul><ul><li>Cardiac Rehab: assessment and modification of risk factors--> Secondary-prevention centers </li></ul>
  6. 6. Cardiac Rehabilitation-4 <ul><li>Exercise after MI: reduced overall and cardiac causes of mortality </li></ul><ul><li>Decreased rates of subsequent coronary events and hospitalizations </li></ul><ul><li>More efficient and effective than individual physician care: most care providers: </li></ul><ul><ul><li>not fully trained in cardiac rehab techniques </li></ul></ul><ul><ul><li>inadequate time for effective nutritional advice, weight mgmt, exercise prescription </li></ul></ul>
  7. 7. Cardiac Rehabilitation-5 <ul><li>Appropriate subjects: </li></ul><ul><ul><li>AMI </li></ul></ul><ul><ul><li>Coronary revascularization </li></ul></ul><ul><ul><li>Chronic stable angina pectoris </li></ul></ul><ul><ul><li>CHF </li></ul></ul><ul><ul><li>Post cardiac transplant </li></ul></ul><ul><li>Goals: </li></ul><ul><ul><li>Prevent disability </li></ul></ul><ul><ul><li>Prevent subsequent coronary events </li></ul></ul>
  8. 8. Exercise Training <ul><li>Cardiac arrest: 1/112,000 patient-hours </li></ul><ul><li>Non-fatal MI: 1/294,000 patient-hours </li></ul><ul><li>Mortality: 1/784,000 patient-hours </li></ul><ul><li>Exercise capacity:(aerobic conditioning, 3x/wk, over 3 mo) </li></ul><ul><ul><li>increase by 30-50% </li></ul></ul><ul><ul><li>peak O2 consumption inc. 15-20% </li></ul></ul><ul><ul><li>Subjective improvement in performance of ADLs (climbing stairs, carrying groceries) </li></ul></ul><ul><li>Higher angina threshold due to lower HRxBPs product as a result of aerobic conditioning </li></ul><ul><li>Physiologic adaptations are both central (cardiac) and peripheral (skeletal muscle and vascular) </li></ul>
  9. 9. The Bottom Line <ul><li>Long-term mortality from CV and all causes (meta-analyses ‘70s-’80s) </li></ul><ul><ul><li>Cardiac rehab w/ 25% reduction in overall and CV mortality over 3 years </li></ul></ul><ul><li>Why? </li></ul><ul><ul><li>Improved lipids </li></ul></ul><ul><ul><li>Improved coronary blood flow </li></ul></ul><ul><ul><li>Reduced obesity </li></ul></ul><ul><ul><li>Improved HR variability and autonomic tone </li></ul></ul><ul><ul><li>Increased fibrinolysis </li></ul></ul><ul><ul><li>Improvement in psychological factors </li></ul></ul><ul><li>EXERCISE TRAINING IMPROVES FNL CAPACITY, REDUCES SXS IN PTS W/ CAD, & REDUCES OVERALL AND CV MORTALITY </li></ul>
  10. 10. Cardiac Rehab in DM-2 <ul><li>Ongoing drug therapy (insulin, oral hypoglycemic agents) and need for exercise-related dose adjustments </li></ul><ul><li>Techniques of self-monitoring have become essential to pursue effective and safe exercise rehabilitation </li></ul><ul><li>Complications (retinopathy, neuropathy, nephropathy) all affect exercise prescription </li></ul><ul><li>Higher prevalence of silent ischemia requires careful monitoring </li></ul>
  11. 11. BENEFIT IN TYPE 2 DM <ul><li>59 DM2 pts (vs 36 age-matched non-DM controls) </li></ul><ul><li>2 month program after acute coronary event </li></ul><ul><li>After program, improvement in exercise capacity lower in diabetic pts </li></ul><ul><li>In pts with DM, significant inverse relation btw FBS and change in peak VO2 </li></ul><ul><li>Thus, degree of glycemic control may have important implications in success of exercise rehabilitation in this cohort. </li></ul><ul><li>Verges, et al. Diabet Med. 2004 Aug:21 (8): 889-95 </li></ul>
  12. 12. RESULTS OF CARDIAC REHAB IN PTS WITH DM <ul><li>In 2003 study, 26% of pts in a program at Boston Medical Ctr. had DM </li></ul><ul><ul><li>53% taking insulin &/or oral hypoglycemic medication </li></ul></ul><ul><li>Greater risk profile, with higher prevalence of </li></ul><ul><ul><li>hypertension -PVD </li></ul></ul><ul><ul><li>obesity -lower ex. Capacity </li></ul></ul><ul><li>Initial Hgb A1C 8.4% </li></ul><ul><li>Fewer DM pts completed program (38% vs 48%) </li></ul><ul><ul><li>exacerbation of medical problem (both cardiac and noncardiac) cause of dropout (29% vs. 18%) </li></ul></ul><ul><li>Banzer et al., AmJCard 93 (1) 2004 Jan1 (81-84) </li></ul>
  13. 13. APPROACH TO INVOLVEMENT OF DIABETIC PATIENT IN CARDIAC REHABILITATION <ul><li>At intake appt, nurse card mgr reviews program guidelines with participant and involves PCP re: medication or diet adjustments before starting program </li></ul><ul><li>Classroom “Diabetes 101” review of diabetic guidelines for exercise </li></ul><ul><li>Participants encouraged to bring their own monitors (checked for accuracy by Program Monitor…+/- 20% acceptable accuracy) </li></ul><ul><li>BG monitored 15-30 min prior to exercise, and post-exercise for at least 3 sessions </li></ul><ul><li>If BG out of range, set protocol for intervention and consultation with PCP </li></ul>
  14. 14. PROTOCOL
  15. 15. TREATMENT OF HYPOGLYCEMIA <ul><li>50-100 mg/dl: 15 gm CHO; repeat BG testing after 15 minutes. May exercise when BG >120 mg/dl </li></ul><ul><li><50 mg/dl: 30 gm CHO. Consider glucagon. Repeat BG testing after 15 minutes. Repeat CHO until BG >120 mg/dl and free of hypoglycemic sxs. </li></ul>
  16. 16. VALUE OF CARDIAC REHABILITATION IN DM <ul><li>The participant understands the importance of regular exercise as part of a comprehensive medical management strategy: “ EXERCISE IS MEDICINE” </li></ul><ul><li>Establishes a habit and a rhythm of regular participation </li></ul><ul><li>Teaching safe methods of exercise </li></ul><ul><ul><li>avoidance of pre- or post-exercise hypoglycemia </li></ul></ul><ul><ul><li>encourages choice of exercise appropriate to particular condition (neuropathy, retinopathy, nephropathy) </li></ul></ul><ul><ul><li>Encourages frequent testing as guide to safe approach </li></ul></ul><ul><li>Participant understands diabetes as part of a collection of coronary risk factors--inspires patient to take responsibility for own medical condition </li></ul>
  17. 17. Effects on Coronary Risk Factors <ul><li>Lipids: 8-23% increase in HDL </li></ul><ul><li>Increase of chol/HDL = 5-26% </li></ul><ul><li>However, exercise training alone: </li></ul><ul><ul><li>Minimal effect on LDL </li></ul></ul><ul><ul><li>0-2% change in body wt at 3 months </li></ul></ul><ul><ul><ul><li>-5% fat mass, +2% muscle mass </li></ul></ul></ul><ul><ul><li>Improved glucose tolerance and less insulin resistance </li></ul></ul>
  18. 18. Exercise Prescription <ul><li>Consider risk factors, age, functional status </li></ul><ul><li>Moderate to high intensity, 3-5x/wk, 25-45 min per session </li></ul><ul><li>Low caloric expenditure: 270-283 kcal/session, not likely to induce wt loss without dietary changes </li></ul><ul><li>Regimen of low-intensity, prolonged daily exercise (“high caloric training”) leads to greater fat loss than more intense briefer sessions </li></ul><ul><li>Important to include resistance training to minimize loss of muscle mass </li></ul><ul><li>Intervals of relatively intense exercise may lead to improvement in endothelium-dependent coronary vasodilation after 4 wks. </li></ul>
  19. 19. Summary of Components and Goals <ul><li>Initial history and physical examination </li></ul><ul><li>Control hypertension </li></ul><ul><li>Smoking cessation </li></ul><ul><li>Weight loss if BMI > 25 </li></ul><ul><li>DM control </li></ul><ul><li>Psychosocial adjustments </li></ul><ul><li>Physical activity counseling and exercise prescription and training </li></ul><ul><li>Enhance compliance: </li></ul><ul><ul><li>Exercise: 50% at one year --anti-htn meds: 64% </li></ul></ul><ul><ul><li>lipid-lowering meds: 82% --f/u necessary after program </li></ul></ul>
  20. 20. Comprehensive Risk Reduction <ul><li>Smoking: decision to stop is central </li></ul><ul><ul><li>Unequivocal message from health professionals </li></ul></ul><ul><ul><li>Pick a date --Involve important others </li></ul></ul><ul><ul><li>Behavioral skills for coping with stress, possible use of bupropion &/or nicotine supplements </li></ul></ul><ul><ul><li>Followup </li></ul></ul><ul><li>Hyperlipoproteinemia </li></ul><ul><ul><li>Diet --Medications --Exercise -- Followup </li></ul></ul>
  21. 21. Comprehensive Risk Reduction-2 <ul><li>Weight-loss </li></ul><ul><ul><li>May lead to 4-9% reduction when exercise w/ dietary intervention </li></ul></ul><ul><ul><li>Improved lipid levels, insulin resistance, BP, clotting abnormalities </li></ul></ul><ul><ul><li>Stimulus control (behavioral changes) </li></ul></ul><ul><ul><li>Self-monitoring </li></ul></ul><ul><ul><li>Social support (non-judgmental) </li></ul></ul><ul><ul><li>Daily calorie count and recording </li></ul></ul><ul><ul><li>5-10% reduction in bw may be sufficient to improve lipids and insulin resistance </li></ul></ul>
  22. 22. Comprehensive Risk Reduction-3 <ul><li>BP and DM-2 benefited by exercise training, weight loss, and improved diet </li></ul><ul><li>Self-monitoring of BP and DM important skills to learn; will help PCP management </li></ul><ul><li>Psychological Factors: </li></ul><ul><ul><li>Cardiac rehab improves measures of </li></ul></ul><ul><ul><ul><li>anxiety + emotional stress +self-confidence </li></ul></ul></ul><ul><ul><ul><li>depression +social isolation +quality-of-life </li></ul></ul></ul>
  23. 23. Challenges <ul><li>Extension of services to indigent and uninsured </li></ul><ul><li>Geographic issues, especially in rural states </li></ul><ul><li>Reaching appropriate patients: </li></ul><ul><ul><li>In hospital screening and recruitment </li></ul></ul><ul><ul><li>Prioritize communication and involvement of cardiologist and PCP for referral and close followup </li></ul></ul><ul><li>Individualize programs </li></ul><ul><ul><li>to be appropriate for elderly, younger patients, the physically challenged, and the remotely situated </li></ul></ul><ul><ul><li>risk-factor modifications appropriate for each case </li></ul></ul><ul><ul><li>emphasize the payoff: physical, behavioral, and risk-factor changes that will lead to improved outcomes </li></ul></ul>
  24. 24. Helpful Resources <ul><li>Philip A. Ades, MD, Cardiac Rehabilitation and Secondary Prevention of Coronary Heart Disease NEJM 2001; 345:892-902. </li></ul><ul><li>Wenger, NK et al , Cardiac rehabilitation: clinical practice guidelines , 1995 (AHCPR publication no. 96-0672) </li></ul><ul><li>DeBusk, RF, et al Case-mgmt system for coronary risk-factor modification after AMI Ann Int Med 1994: 120: 721-729 </li></ul><ul><li>Linden W, et al Psychosocial interv for pts w cad: meta-analysis Arch Int Med 1996; 156: 745-752 </li></ul>