Post on 29-Dec-2015
Heart Disease!UCLH Trust Members 2010
Dr Malcolm Walker
Consultant Cardiologist
UCLH & the Heart Hospital
Dr Malcolm WalkerConsultant Cardiologist - general adult
interventional cardiologist with special interests in rehabilitation and myocardial iron overloadDirector of Hatter Cardiovascular Institute
UCHImmediate past president British Association
of Cardiovascular Rehabilitation (BACR)Scientific board member of the Thalassaemia
International Federation (TIF – a WHO sponsored NGO - a patients & families lobby)
Question
“What treatment has randomised trial evidence of long term benefit by mortality reduction of >20%, morbidity reduction of a similar magnitude, causes weight loss, reduces blood pressure, improves mood, improves functional capacity, raises HDL cholesterol, improves glucose metabolism and does not cost the earth?”
Heberden 1772“one patient nearly cured himself of his
angina” by retreating to his country estate “and sawing wood every day for some months”
Case history:
June 2003
59 yr old male
Collapse – Rx DCC CPR
Urgent angiography
Urgent CABG
Case history:
June: Emergency CABG
October …..
7 Marathons in 7 days
Does fitness affect Does fitness affect survival ?survival ?
• After Myocardial infarctionAfter Myocardial infarction
• In primary preventionIn primary prevention
Cooper Clinic experienceCooper Clinic experienceBlair et al JAMA 1989Blair et al JAMA 1989
0
5
10
15
20
25
30
12345
% Dead
Category of Fitness from 1 (low) to 5 (very fit)
Does fitness affect Does fitness affect survival ?survival ?
• After Myocardial infarctionAfter Myocardial infarction
• In primary preventionIn primary prevention
Harvard alumni studyHarvard alumni study
ExerciseExercise No No exercisexercis
ee
ModeratModeratee
StrongStrong Very Very stronstron
ggOverweightOverweight
BMI>27.5BMI>27.521%21% 16%16% 13%13% 10%10%
Current Current smokersmoker
17%17% 9.4%9.4% 6.8%6.8% 4.8%4.8%
Alcohol Alcohol >7/wk /wk>7/wk /wk
37%37% 42%42% 42%42% 44%44%
Red meat Red meat
>3/wk>3/wk40%40% 34%34% 29%29% 28%28%
Vegetables Vegetables
< 6 /wk< 6 /wk30%30% 25%25% 23%23% 22%22%
Harvard alumni studyHarvard alumni studyNo No
exercisexercisee
ModeratModeratee
StrongStrong Very Very strongstrong
Relative Risk Relative Risk of CHD of CHD
Age adjustedAge adjusted
1.01.0
ReferentReferent0.810.81
(0.62-1.04)(0.62-1.04)0.640.64
(0.48-(0.48-0.85)0.85)
0.600.60
(0.44-(0.44-0.81)0.81)
Relative Risk Relative Risk of CHDof CHD
Multivariate Multivariate adjadj
1.01.0
ReferentReferent0.810.81
(0.62-1.06)(0.62-1.06)0.620.62
(0.46-(0.46-0.84)0.84)
0.600.60
(0.44-(0.44-0.83)0.83)
Relative Risk Relative Risk of CHDof CHD
Multivariate Multivariate adjadj
1.01.0
ReferentReferent0.860.86
(0.66-1.13)(0.66-1.13)0.690.69
(0.51-(0.51-0.94)0.94)
0.720.72
(0.52-(0.52-1.00)1.00)
REDUCED REDUCED RISKRISK
20%20% 40%40% 40%40%
pp for trend for trend 0.00020.0002 0.00030.0003 0.020.02
Harvard alumni - summaryHarvard alumni - summary
• Self reported Borg-type scale usefulSelf reported Borg-type scale useful• Graded benefit according to amount Graded benefit according to amount
of exercise, when compared to those of exercise, when compared to those not doing anynot doing anySo not everybody has to wear So not everybody has to wear lycra pants & join a gymnasiumlycra pants & join a gymnasium
• Limitations of the study:Limitations of the study:– Men, American, higher social classMen, American, higher social class
Walking – benefit to high risk Walking – benefit to high risk group demonstratedgroup demonstrated
• Decreased death rate in diabeticsDecreased death rate in diabetics– 2896 adults with diabetes2896 adults with diabetes– Those walking >2hr per weekThose walking >2hr per week
•39% lower all cause mortality39% lower all cause mortality
•34% lower cardiovascular mortality34% lower cardiovascular mortality
– Largest benefit in those walking 3-4hr per Largest benefit in those walking 3-4hr per week and for those reporting moderate week and for those reporting moderate increase in heart rate & breathing rateincrease in heart rate & breathing rate
Arch Intern Med 2003; 163: 1440-1447
Exercise as therapy in CHDExercise as therapy in CHD
BUT can we provide an intervention that works?
Cardiac RehabilitationCardiac Rehabilitation
• The patients can do moreThe patients can do more
• Their cholesterol is lowerTheir cholesterol is lower
• They are taking their tablets They are taking their tablets regularlyregularly
• They are no slimmerThey are no slimmer
Is anything more being achieved for them?
Taylor, R.S. et.al. Am J Med 2004Hospitalised for CHD48 RCTs, n= 894020% reduction in all cause mortality 24% in
cardiovascular mortalityGains still evident when statins given to both arms
of trial
Cardiac Rehabilitation in CHD
So exercise does matterBoth for “victims” of CHD and as a method of
prevention
Cardiovascular RehabilitationWhy?
Because there is good evidence that it helps
Because we’ve been told to..
NSF CHD – Cardiac Rehabilitation
Chapter 7 (Standard 12)“NHS Trusts should put in place agreed
protocols/systems of care so that, prior to leaving hospital, people admitted to hospital suffering from coronary heart disease have been invited to participate in a multidisciplinary programme of secondary prevention and cardiac rehabilitation.”
NSF Goal“Every hospital should ensure
a) that more than 85% of people with a primary diagnosis of AMI are offered cardiac rehabilitation.
Cardiovascular RehabilitationWhy?
Because there is good evidence that it helpsRandomised control trial (RCT) data
Because we’ve been told to..NSF
Because there is an unmet need
% Eligible patients offered CR England & Wales
19971997 20002000 20052005
AMIAMI 14 – 2314 – 23 1717 2525
CABGCABG 33 – 5633 – 56 4444 6565
PCIPCI 6 – 106 – 10 66 1010
Surveys by Dr Hugh Bethel – BACR/BHF
University College Hospital Foundation TrustCardiovascular Health & Rehabilitation
2005 Co-operative bid with Camden PCT for BHF NOF funding – Grant £120,000To develop a new self management method to deliver
CR in association with Prof Stan NewmanAims to reduce DNA ratesImprove adoption & maintenance of behaviour
changePlan to roll out to whole sector & beyond if
successful
UCH Cardiovascular Health & Rehabilitation
Patient recruitmentHeart Hospital
Cardiology patients identified from cath. lab databaseAll receive standard letter or contacted by telephoneCamden patients reviewed whilst in-patients – if time
N.B. all Heart hospital patients (90+) are eligible for CR!
Surgical patients referred by surgical audit teamUCH
Daily ward round AAU – most eligible patients will transfer to Heart Hospital
Number of Patients referred to CR
0
500
1000
1500
2000
2500
2001 2002 2004 2005
No. Patients
Currently represents between 88-92 % of eligible patients
Number of patients referred for CR at UCH CV Health
0
50
100
150
200
250
300
350
400
2001 2002 2004 2005 2006
No. Patients
UCH Cardiovascular Health & RehabilitationUCH Cardiovascular Health & Rehabilitation
UCH Cardiovascular Health UCH Cardiovascular Health & Rehabilitation& Rehabilitation
Important service characteristicsImportant service characteristics Close liaison with sector – rehabilitation task Close liaison with sector – rehabilitation task
groupgroup Evidenced by Patient choice funding & Combined BHF Evidenced by Patient choice funding & Combined BHF
NOF bidNOF bid Strategic alliance with central YMCA 2003Strategic alliance with central YMCA 2003
Exercise classes move out of hospital environmentExercise classes move out of hospital environment Exercise professionals supported through BACR trainingExercise professionals supported through BACR training
Flexibility – timing, course structure & contentFlexibility – timing, course structure & content Menu of choices for patientsMenu of choices for patients
Early adoption of national (BACR/ BHF/ York Early adoption of national (BACR/ BHF/ York University) minimum datasetUniversity) minimum dataset
Introduction of self-management programme Introduction of self-management programme
UCH Cardiovascular Health UCH Cardiovascular Health & Rehabilitation& Rehabilitation
New developmentsNew developments Expanded remitExpanded remit
Heart failure – initially from hospital clinics, Heart failure – initially from hospital clinics, expanding to offer to primary care – now in full expanding to offer to primary care – now in full swingswing
““Primary” prevention in diabetics – initially from Primary” prevention in diabetics – initially from hospital clinic with a view to expand to primary hospital clinic with a view to expand to primary care – supports existing initiative of Camden Active care – supports existing initiative of Camden Active Health TeamHealth Team
Improve accessibilityImprove accessibility Walk in assessment service – as per R1Walk in assessment service – as per R1
Pilot with one local primary care provider in first instancePilot with one local primary care provider in first instance
Conclusions on Conclusions on Cardiovascular Cardiovascular RehabilitationRehabilitation
Task worth the effortTask worth the effort CR evidence is compellingCR evidence is compelling Anecdotal experience will amplify!Anecdotal experience will amplify!
Individuals committed to the service Individuals committed to the service Trained to deliver high quality CR – use BACR/ ACPIR resourcesTrained to deliver high quality CR – use BACR/ ACPIR resources
Good quality dataGood quality data National CR audit makes this easierNational CR audit makes this easier Simple local databases are a starting point – get your kids to Simple local databases are a starting point – get your kids to
design you one!design you one! Good quality communicationGood quality communication
Fax, telephone, e-mail !Fax, telephone, e-mail ! CR administrator invaluable/ CR administrator invaluable/ sine qua nonsine qua non ? ?
It’s mostly about teamwork!It’s mostly about teamwork!