I’ve had a heart attack – now what do I do with my life?

(Driving, work, sexuality and coping)

William Dafoe, Associate Professor of Medicine, Division of Cardiology

Oct. 3, 2011

Handouts – patient resources

Handouts

What is Cardiac Rehabilitation?

Cardiac rehabilitation services are comprehensive and long-term involving 1) medical evaluation 2) prescribed exercise 3) cardiac risk factor modification 4) education and counseling

Cardiac Rehabilitation(CACR definition)

“the enhancement and maintenance of cardiovascular health through individualized programs designed to optimize physical, psychological, social, vocational and emotional status.

This process includes the facilitation and delivery of secondary prevention through heart hazard (i.e. risk factor) identification and modification in an effort to prevent disease progression and the recurrence of cardiac events”.

Patient Selection

Exercise Education

Risk factormodificationPsychosocial

Support

*Family *Friends*Counsellor *MD

*MD *Lipid clinic* smoking cessation* BP clinic etc.

*Mobilization*Vocation *Recreation*Home ex. program

*MDT *books* media *family* friends

Cardiac RehabilitationProgram

Cardiac RehabilitationServices

Cardiac RehabilitationServices

CLIENT GROUPS

CONDITIONS / INTERVENTIONSCoronary Artery DiseaseCongestive Heart Failure

CardiomyopathyValvular Disease

Congenital Heart Disease

Coronary Artery Bypass SurgeryPercutaneous Interventions (Stents)

Pacemaker / Resynchronization TherapyImplantable Defibrillators

Transplant

SPECIAL FACTORSGender

AgeEthnicity

Socio-Economic StatusDemographics

High-risk primary prevention

CO-MORBIDITIESDiabetesObesity

Pulmonary DiseaseArthritisCancer

Chronic Renal FailurePeripheral Artery DiseaseAdapted from:

CACR Guidelines for Cardiac Rehabilitation and Cardiovascular Disease Prevention 2004

ELIGIBILITY

Case #1 Jane Doe

Jane Doe

• NSTEMI after shoveling snow• BMS to the LAD• very concerned and worried about her heart disease

• husband George, 64 years old• has chronic back pain, unemployed

Randall – 26 year old son• drove up from Red Deer to be withhis “dear Mom” after he heard she had a ‘heart attack’

Would she benefit from cardiac rehabilitation even though she says she

can’t make it to the Glenrose?The Van Damme & Dafoe Exchange

Benefits for women

• Fellowship• Feeling safe during exercise• Skills acquisition

–Empowerment–Responsibility for one’s health–Role model for family

© 2011 American Heart Association, Inc. Published by American Heart Association. 2

Figure 3

Dose Response Between Physical Activity and Risk of Coronary Heart Disease: A Meta-Analysis.Sattelmair, Jacob; MSc, ScD; Pertman, Jeremy; Ding, Eric; Kohl, Harold; Haskell, William; Lee, I-Min; MBBS, ScD

Circulation. 124(7):789-795, August 16, 2011.DOI: 10.1161/CIRCULATIONAHA.110.010710

Figure 3 . Generalized least squares (GLST) regression spline (smoothed fit) models with 95% confidence intervals (CIs). CHD indicates coronary heart disease; LTPA, leisure-time physical activity.

Basic activity (550 kcal) – 150 minutes/wk of moderate-intensity (3 – 6 METs)Or – 75 min of vigorous intensity (>6 METs)Men – 9% lower risk than baseline.Women – 20% lower risk than baseline

Advanced activity (1100 kcal) – 300 min/wk moderate intensityOr – 150 min of vigorous intensity Men – 18% lower risk than baselineWomen – 28% lower risk than baseline

21%

48%

Based on only 2 studies

9% 18% 20%

28%

She asks you about ‘stress’ in her life. She thinks that this is one of the main causes of her getting heart disease. What would be

your answer?

Stress as a factor

• Circadian variation in MI frequency• Acute coronary syndromes precipitated by

emotional distress, life events, disasters• Personality types associated with CAD

(type A, depression)• Major depression post MI associated with

poor outcome

Case Study #2Fred Brown (aka ‘Red’)

You decide to do an EST, what protocol would you use?

• 4 - 7 days post MI: Low Level EST (Modified Bruce)

End Points are 9 minutes, 5 METs, and/or 70% of maximum heart rate.

• 14-21 days post MI: Symptom-Limited

Adapted from ACC/AHA guidelines 2002

Approximately 9 minutes into exercise (equivalent to 4.5 METS), you notice -1.0 mm of horizontal ST depression beyond his baseline ST abnormalities in his lateral leads. He has no complaints of chest pain but does have shortness of breath. Would you stop the test? What is the significance of the ST depression?

What are your recommendations regarding sexual activity? Would you re-fill his prescription for Viagra?

Sexual Activity and Cardiac RiskSexual inquiry

Clinicalevaluation

Low risk Indeterminate risk High risk

Cardiovascularassessment andrestratification

• Initiate or resumesexual activity

or• Treat sexual

dysfunction

• Sexual activitydeferred untilstabilization ofcardiac condition

From DeBusk et al. American Journal of Cardiology (2000) 86:175-181.

LOW Risk Category• Asymptomatic, <3 risk factors for CAD (excluding

gender)• Controlled hypertension• Mild, stable (evaluated and / or being treated) angina• Uncomplicated post MI (>4 months)• Post-successful coronary revascularization• Mild valvular disease• Congestive heart failure (left ventricular dysfunction

and/or NYHA class I)– Can initiate sexual activities without further evaluation– No significant cardiac risk associated with sexual

activities

Low-risk PatientsManagement

No special cardiac testing or evaluation prior to resuming sexual activityPrimary care management– Consider all first-line therapies– Reassess at regular intervals (6-12

months)

High-risk PatientsDefinition

Cardiac condition sufficiently severe and/or unstable that sexual activity may constitute significant risk– Unstable or refractory angina– Uncontrolled hypertension– Congestive heart failure (NYHA class III/IV)– Recent MI (< 2 weeks)– High-risk arrhythmias– Hypertrophic obstructive and other cardiomyopathies– Moderate to severe valvular disease

High-risk PatientsManagement

Sexual activity should be deferred until cardiac condition stabilized by treatment or cardiologists/internist determines that sexual activity can be safely resumed– Priority referral for specialized CV

management

Sexual Activity and Cardiac RiskSexual inquiry

Clinicalevaluation

Low risk Indeterminate risk High risk

Cardiovascularassessment andrestratification

• Initiate or resumesexual activity

or• Treat sexual

dysfunction

• Sexual activitydeferred untilstabilization ofcardiac condition

From DeBusk et al. American Journal of Cardiology (2000) 86:175-181.

MET level during Sexual Activity

0

0.5

1

1.5

2

2.5

3

3.5

4

baseline excitement-intromission

orgasm

MET

s

WOT MOT partner stim self-stim

RPP during Sexual Activity

2000

7000

12000

17000

22000

baseline excit ement -int romission

orgasm 30s 60s 120s

Nemec-WOT Nemec-MOTBohlen- MOT Exton-self-stim FBohlen-self-stim M

Resolution

“Sex is physically similar to 2 flights of stairs” (Larson et al, 1980)

• Compared HR and BP responses to sexual activity & stair climbing

• CAD pts. monitored while they walked for 10 min. at 4.8 km/hr, then climbed 22 steps in 10 seconds

• HR and BP measured after sex and climbing stairs

Can he participate in recreational hockey?

“For all participants, maximum heart rate (HRmax) (mean 184) was greater thantarget exercise heart rate”

“mean period for which heart rate exceeded 85% of the age-predicted HRmax was 30 (SD 13) min”

“physical activity pattern that occurred during recreational hockey causedcardiac responses that might be dangerous to players’ health”

CMAJ • FEB. 5, 2002; 166 (3)

* Risk of body collision, increased demands from competitionTask Force 8: classification of sports. J Am Coll Cardiol 2005; 45:1364.

“I certainly don’t want to go out and play a hockey gameand have my wife or my children wondering what the risk is,

whether it’s 1 percent, 10 percent or half a percent,”

‘Few in the NHL played with as much heart as Steve Konowalchuk,making the reason he is giving up the game at age 33 so painfully ironic.’

“Exercise Prescription”(low to moderate)

• Attempt to find out motivation and underlying belief systems

• Explain rationale of health effects of exercise

• Simple methods– 30 minutes of some aerobic activity per day– 10,000 steps of a pedometer

Moderate to high• 60 – 80% max HR

– .6 x 145 = 85 .8 x 145 = 116• HRR reserve (max HR – resting HR) = 70

– (.6 x 70) + 75 = 117– (.8 x 70 ) + 75 = 131

• Consider ischemic threshold• If very deconditioned, could benefit from an

intensity of 40%• Include resistance and flexibility exercises• Determination of pulse (or Polar monitor)

Case Study #2Can he go back to farming?

https:// /

Case Study # 3Violet York

Questions

What questions need to be asked in order to determine whether her chest tightness is non-cardiac, atypical or typical?

Women and Heart Disease

What is my Angina?“My symptoms are so difficult to describe!” “Every ache and pain

in my chest reminds me of my angina, and I’m afraid to do anything!”

“I feel like every time I have chest pain, I am having

another heart attack!!”

Defining Angina• The confusion over what is true angina and what

is non-cardiac pain is very distressing and can interfere with exercise compliance (Gallagher et al, 2003)

• “A greater trust in the heart-diseased body” has been implicated in fostering the confidence to make behavioural changes long-term (Clark et al.,2005)

• Learning strategies for stress management, knowing one’s physical limits, and the ability to define angina are all predictors for ongoing compliance in CR and beyond (Van Damme, 2009)

Does menopause make a difference?

• A study conducted by Norris et al., 2008, found that overall women presented with more prodromal symptoms than men prior to ACS.

• In addition, they found that there were variations in prodromal symptoms among the women based on menopausal status.

• The pre-menopausal and peri-menopausal reported a greater number and higher frequency of symptoms prior to an ACS presentation.

Can Mrs. York return to work?

Would you do any other investigations?

Vocational Issues• Evaluate if return-to-work (RTW) is safe and

realistic• Consider factors influencing RTW• Expedite the resumption of gainful employment• Evaluate Employment Determination (Capability

of person to perform job, Risk to self involved in performing the job, and Risk to society if the person performs the job).

• Discuss potential job modifications.