Benefits of Cardiac Rehabilitation:Benefits of Cardiac Rehabilitation:

Impact on Mortality, Hospitalizations Impact on Mortality, Hospitalizations and Risk Factorsand Risk Factors

Reggie Higashi, MSSReggie Higashi, MSS

Exercise PhysiologistExercise Physiologist

Core Program Components

• Baseline clinical evaluation Baseline clinical evaluation & patient assessment & patient assessment

• Risk factor management Risk factor management and goal settingand goal setting

• Psychosocial managementPsychosocial management• Physical activity counselingPhysical activity counseling• Exercise training Exercise training

Balady, G. et al. Core components of cardiac rehabilitation/secondary Balady, G. et al. Core components of cardiac rehabilitation/secondary prevention programs: A statement for healthcare professionals from prevention programs: A statement for healthcare professionals from the American Heart Association and the American Association of the American Heart Association and the American Association of Cardiovascular and Pulmonary Rehabilitation. Cardiovascular and Pulmonary Rehabilitation. CirculationCirculation, 2000; , 2000; 102:1069-1073.102:1069-1073.

Approved Diagnoses(Medicare)

• Myocardial infarction Myocardial infarction – Within 1 yearWithin 1 year

• Stable anginaStable angina• Coronary artery bypass grafting Coronary artery bypass grafting

– Within 1 yearWithin 1 year

Ref: Section 35:25 of the "Medicare Procedure Ref: Section 35:25 of the "Medicare Procedure Manual" Cardiac Rehabilitation ProgramsManual" Cardiac Rehabilitation Programs

Approved Diagnoses(Non-Medicare)

• Myocardial infarctionMyocardial infarction• Stable anginaStable angina• CABG CABG • PTCA/Stent placementPTCA/Stent placement• Heart failureHeart failure• PADPAD• Recent ICD implantRecent ICD implant• ArrhythmiasArrhythmias• Valve replacement/repairValve replacement/repair• Heart transplantHeart transplant

Cardiac Rehab Programs

• Monitored outpatient program– 3 days/week for up to 12 weeks– Covered by Medicare (MI, angina, CABG)

• Modified monitored outpatient program– 3 days/week for up to 4 months– Not covered by insurance

• Extended outpatient program (after monitored or modified program)– 3 days/week for up to 4 months– Not covered by insurance

• Maintenance program (after extended program)– 2 days/week

Monitored Outpatient Program

• One hour cardiac monitored exercise sessions

• 3 days/week, MWF for up to 12 weeks• Various class times in morning and afternoon• Guided warm-up, three 10-minute aerobic

stations, guided cool-down• Blood pressure monitored pre, during and

post-exercise• Monthly and final reports sent to referring

M.D.• Medicare/Insurance covered diagnoses (MI,

CABG, Stable Angina)

Modified Monitored Outpatient Program

• Telemetry monitored for first 2 weeks, then patient is placed on personal heart rate monitor for the remainder of program

• 3 days/week, MWF for up to 4 months enrollment limit• Various class times in morning and afternoon• Guided warm-up, three 10-minute aerobic stations,

guided cool-down• Blood pressure monitored pre, during and post-

exercise• Monthly and final reports sent to referring M.D.• Costs: $325 for initial month (includes costs of

personal heart rate monitor) then $40 per month for the remaining 3 months.

• (Self-Pay; Not covered by insurance)

Extended Outpatient Program

• One hour non cardiac-monitored exercise sessions• 3 days/week, MWF for up to 4 months enrollment limit• Various class times in morning and afternoon• Guided warm-up, three 10-minute aerobic stations,

guided cool-down• Blood pressure monitored pre, during and post-exercise• Cardiac monitoring 1x/month• Monthly reports with telemetry cardiac monitoring sent

to referring M.D.• Self Pay: $40/month (Not covered by insurance)

– Must complete monitored or modified monitored program to enroll in this program.

Maintenance Program

• One hour non cardiac-monitored exercise sessions• 2 days/week, Tu & Th, 8:00 a.m. - 9:00 a.m. • Guided warm-up, four 10-minute aerobic stations,

guided cool-down• Blood pressure monitored 1x/month as as needed• Heart Rate checks pre, during and post-exercise by

patient• Copy of monthly exercise logs given to patient.• Self Pay: $30/month (not covered by insurance)

– Must complete extended out-patient program to enroll in this program.

Effect of Exercise-Based Cardiac Rehab on Cardiac Events in

Patients with CAD (MI, angina, CABG, PCI)

Exercise Only

Comprehensive Program

Non-fatal MI

- 4% - 12%

Cardiac Mortality

- 31% * - 26% *

Jolliffe et al. Meta-Analysis, 2001. 51 randomized, controlled trials (n = 4,000)2 –6 months of supervised rehab, then unsupervised Mean follow-up of 2 – 4 years

Utilization of Cardiac Rehab by Patients After MI

• Ades et al , 1992 reviewed utilization of cardiac rehab by patients within 1 hour of rehab center

• Age Dependence of Utilization– < 62 yrs: 46% utilization– > 62 yrs: 21% utilization– Most powerful predictor of utilization

was recommendation of primary care physician to participate

Potential Explanation for Reduced Mortality Without Impact on Non-

fatal MI

• Ischemic preconditioning– Animals having repeated episodes

of temporary coronary occlusion have smaller MI when occlusion is permanent

• Electrical stability and reduced ventricular fibrillation

Exercise Training in Patients with Angina

• Improved myocardial oxygen supply at a given level demand– Increase in rate pressure product at onset

of angina (reduction in exercise heart rate)– Decrease in nuclear scan perfusion defects

(as early as 8 weeks)– Less ST segment depression

• Proposed mechanisms– Improved endothelial function (angio

studies)– Increased coronary collaterals– Regression and reduction in progression of

CAD (1 yr studies)

Exercise Training After Coronary Revascularization (CABG/PCI)

• No large studies• ETICA Trial (Exercise Training Intervention after

Coronary Angioplasty Trial, 2001• 118 patients underwent 6 months of exercise

training or control. Follow-up of 33 + 7 months• Improved exercise capacity (26% increase in v02)• Fewer cardiac events (12 vs 32%)• Fewer hospital admissions (19 vs. 46%)• No impact on restenosis

Exercise Training for Patients With CHF

• > 20 studies document improvements in– Exercise capacity

• 20% improvement in v02 after 4 weeks• 18 – 34% increase in time on treadmill after 12

wks– Quality of life

• Hospitalization and mortality– Belardinelli et al (Circ, 1999): Small trial that

demonstrated improved exercise capacity, decreased hospitalization and improved 1 yr survival

– HF-ACTION – NIH Study• Compares “usual care” with addition of formal

exercise training• Endpoints of mortality and hospitalization

Exercise Training for Patients with PAD and

Claudication• Improvements in distance to onset of

pain (increased by 179% [225 m]) and distance to maximal tolerated pain (increased by 122% [397 m])

• Improvements with exercise exceed those with meds (I.e., Trental, Pletal)

• Most significant improvements when:– Walking as training– Walking to maximal pain– Training period for 6 months

Meta-Analysis of 21 exercise programs Gardner and Poehlman, JAMA, 1995

• Favorable impact on risk factors– Lipids– Blood pressure– Body weight– Insulin sensitivity

• Enhanced parasympathetic tone• Improved endothelial function• Lower catecholamine levels with exercise

may reduce platelet aggregation

Proposed Mechanisms for Improved Outcomes with

Exercise Therapy

Impact on Risk Factors:Cholesterol Reduction

• LDL decrease of 5% (8 – 12% decrease with combined exercise and diet therapy)

• HDL increase of 4.6%• Triglyceride decrease of 3.7%

Meta-Analysis (2001) of 52 trials, n = 4700, > 12 weeks of training

• Decrease in hemoglobin A1C by 0.5 to 1.0– Mechanisms proposed: Increased insulin

sensitivity and decreased hepatic glucose production

– Data from 9 trials, 337 patients with diabetes mellitus, type 2

• Role of physical activity and weight loss * in preventing type 2 diabetes mellitus in patients at risk – Diabetes Prevention Program (NEJM, 2002)– 58% reduction in onset of diabetes over 2.8 years

(vs 31% reduction with metformin 850 mg BID)

Impact on Risk Factors:Diabetes Mellitus

* Average weight loss of 4.4 kgIncrease activity by 8 met hr/week = 6 mile walk per week

Overall

Normotensive

Hypertensive

Systolic - 3.4 -2.6 - 7.4

Diastolic - 2.4 - 1.8 - 5.8

Impact on Risk Factors:Blood Pressure Reduction

44 Trials, n = 2,674

• Useful as adjunct to behavioral programs

• Results of 12 week exercise program in 281 women– 19% abstain after program (vs 10%)– 12% abstain at 1 year (vs 5%)

Impact on Risk Factors:Smoking

Exercise 2 – 3 kg

Diet 5 – 5 ½ kg

Diet and Exercise

8 ½ kg

Impact on Risk Factors:Weight Reduction

Favorable Effects of Exercise Training

• Endothelial Function• Fibrinolytic System• Platelet Function

Exercise Therapy and Platelet Function

• An increase in platelet aggregation can occur after exercise in sedentary individuals (possibly related to increased catecholamines)

• After 12 week exercise training program, platelet aggregation decreased by 52% in a study of middle age, hypertensive male subjects

Plasma Fibrinogen - 13%

Tissue Plasminogen Activator

+ 39%

Plasminogen activator inhibitor - 1

- 58%

Exercise Therapy and Fibrinolytic System

Summary:Benefits of Exercise-Based Cardiac

Programs

• 30% decrease in mortality in patients with CAD (Decrease in mortality also reported in CHF)

• Decrease in hospitalizations after coronary revascularization and with CHF

• Improved exercise tolerance in patients with claudication and PAD

• Favorable impact on risk factors

Exercise Recommendation(AHA/CDC/ACSM)

• 30 minutes or more of moderate intensity of physical activity on most (preferably all) days of the week

• Moderate intensity– Absolute intensity = 4 – 6 mets *– Relative intensity = 40 – 60% of v02

max

•4 mets may be “vigorous” for an 80 yr old and• “light” for a 20 yr old

Thank you all for attending today’s lecture. Thank you all for attending today’s lecture.

Any Questions???Any Questions???