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!