Post-MI Cardiac Rehabilitation. Mark Mason Consultant Cardiologist Harefield Hospital Royal Brompton and Harefield NHS Foundation Trust

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1 Post-MI Cardiac Rehabilitation Mark Mason Consultant Cardiologist Harefield Hospital Royal Brompton and Harefield NHS Foundation Trust

2 'the sum of activities required to influence favourably the underlying cause of the disease, as well as the best possible, physical, mental and social conditions, so that they (people) may, by their own efforts preserve or resume when lost, as normal a place as possible in the community. Rehabilitation cannot be regarded as an isolated form or stage of therapy but must be integrated within secondary prevention services of which it forms only one facet'.[1] Cardiac Rehabilitation Commissioning guide 2013

3 The 2013 audit[6] has shown that cardiac rehabilitation programmes have seen increasing numbers of patients compared with previous years. Unfortunately, mean uptake to services has not significantly changed, with just 43% receiving cardiac rehabilitation. This is influenced by an increase in the number of cardiology procedures and patients but also influenced by poor uptake of cardiac rehabilitation.

4 Key clinical and quality issues actively identifying all people potentially eligible for cardiac rehabilitation and encouraging them to take part in cardiac rehabilitation Evidence suggests that home- and centre-based cardiac rehabilitation appear to be equally effective in improving the clinical and health-related quality of improving referral, uptake and completion of cardiac rehabilitation programmes comprehensive assessment of an individual, including their need for cardiac rehabilitation developing individualised plans to a person's needs in line with NICE guidance and life the British outcomes Association in for Cardiovascular acute MI and Prevention revascularisation and Rehabilitation standards and core components patients Taylor RS, Dalal H, Jolly K et al. (2010) Home-based versus centre-based cardiac rehabilitation. Cochrane offering hospital-, community- or home-based programmes in line with NICE guidance and evidence-based national programmes providing core components of the programme in line with the British Association for Database Cardiovascular of Prevention Systematic and Rehabilitation Reviews standards Issue and 1: core CD components, including exercise, education, risk factor management and social and psychological support providing the best possible outcomes for individual people/patients, their carers and local communities providing a quality assured service

5 Which patients? For the purpose of this document the following conditions have been included for referral to cardiac rehabilitation: myocardial infarction (MI) including ST-segment-elevation myocardial infarction (STEMI) and non-st-segmentelevation myocardial infarction (NSTEMI) percutaneous coronary intervention (PCI) coronary artery bypass graft (CABG) chronic heart failure implantable cardiac defibrillators (ICD) unstable angina

6 Outcomes of CR 2013 National Audit Cardiac Rehabilitation

7 Post-MI rehabilitation

8 Phases Phase 1 In patient phase Phase 2 Early post-discharge Phase 3 Out patient rehabilitation Phase 4 Maintenance of changed behaviour

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10 How and whom

11 Post-MI rehabilitation Flying post-mi CAA have produced guidance

12 Driving Post-MI rehabilitation Specific concerns If successfully treated by coronary angioplasty, driving may recommence after 1/52 provided: no other URGENT revascularisation is planned (URGENT refers to within 4/52 from acute event) LVEF is at least 40% prior to hospital discharge there is no other disqualifying condition If not successfully treated by coronary angioplasty, driving may recommence after 4/52 provided: there is no other disqualifying condition DVLA need not be notified.

13 Sex Post-MI rehabilitation Reassure patients that after recovery from an MI, sexual activity presents no greater risk of triggering a subsequent MI than if they had never had an MI Advise patients who have made an uncomplicated recovery after their MI that they can resume sexual activity when they feel comfortable to do so, usually after about 4 weeks When treating erectile dysfunction, treatment with a PDE5 (phosphodiesterase type 5) inhibitor may be considered in men who have had an MI more than 6 months earlier and who are now stable

14 Conclusions The evidence base for a staged cardiac rehabilitation strategy is strong This should be tailored to the individual s needs- medical and logistic It requires a concerted effort on the part of all involved Needs to evolve away from traditional hospital-based models