R.P. Zecchin*, J. Baihn, Y.Y. Chai, J. Hungerford, G. Lindsay, M. Owen, J. Thelander, D.L. Ross, C. Chow, A.R. Denniss. Westmead Hospital, Sydney,

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1 R.P. Zecchin*, J. Baihn, Y.Y. Chai, J. Hungerford, G. Lindsay, M. Owen, J. Thelander, D.L. Ross, C. Chow, A.R. Denniss. Westmead Hospital, Sydney, Australia

2 Cardiac rehabilitation is an effective and safe therapy to be used in the management of clinically stable people following myocardial infarction or percutaneous coronary intervention or who have heart failure. (Anderson L, Taylor RS. Cochrane Database Syst Rev. 2014) Treatment options for cardiac patients have evolved over the years and are more evidence-based. There is a paucity of knowledge of the changing characteristics of the patient who commences cardiac rehabilitation today compared to yesteryears, especially in Australia.

3 1. Kotseva et al. Lancet Kotseva et al. Eur J Cardiovasc Prev Rehabil 2015 EA 1 1 EA 2 1 EA 3 1 EA 4 2 N = Years Diabetes (%) (known) 13.0 (undiagnosed) Hypertension (%) TC > 4.5mmol/L (%) NA Smoking (%) Obesity (BMI > 30kg/m 2 )

4 1. Kotseva et al. Lancet Kotseva et al. Eur J Cardiovasc Prev Rehabil 2015 EA 1 1 EA 2 1 EA 3 1 EA 4 2 Anti-Platelets (%) Beta-Blockers (%) ACE-I/ARB (%) Digoxin (%) 7.9 NA NA NA Anti-Coagulants (%) Lipid Lowering (%) NA (Statins only) Nitrates (%) 65.7 NA NA NA CBB (%) NA

5 To examine changes in patient s clinical characteristics, risk factor profiles and medication usage who entered a hospital-based cardiac rehabilitation (CR) program over a period of 20 years.

6 We reviewed and analysed our patients clinical data collected prospectively from January 1995 to December This included age, gender, entry diagnosis, risk factor profiles, functional capacity, and medication usage, Ten time points of two years duration were selected for comparison of data over this time period. Comparisons were made with similar studies involving trend analysis in CR. Statistical analysis was made using non-parametric tests (Kruskal-Wallis H Test and Mantel-Haenszel Test) for linear trend and correlation. Statistical significance was determined at p<0.05. Analysis was performed using the SPSS software version 19 (IBM SPPS).

7 Time Interval (years) (Period 1) (Period 5) (Period 10) p-value N = NS Age (years) <0.001 Gender (female; %) Day to presentation (median days) NS LVEF (%) <0.001

8 (p<0.001) (p<0.045) (p<0.001)

9 Time Interval (years) p-value Hyperlipidaemia (%) <0.001 Smoking (%) <0.001 Diabetes (%) <0.001 BMI (kg/m 2 ) <0.001 Depression (%) <0.001 Hypertension (%) <0.001

10

11 MEDICATIONS TREND p-value Lipid-lowering Increased <0.001 Beta-Blocker Increased <0.001 ACE-I/ARB Increased <0.001 Anti-Depressants Increased <0.001 Anti-Coagulants Increased <0.001 Anti-Arrhythmics Increased <0.025 Digoxin Decreased <0.001 Calcium Channel Blockers (CCB) Decreased <0.001 Long Acting Nitrates Decreased <0.001 Anti-Platelets Unchanged 0.164

12

13 Quality of Life Time Interval (years) p-value Physical Functioning (SF-36) <0.001 Bodily Pain (SF-36) <0.001 Mental Health Scores (SF-36) Depression Scores (DASS 21 ) Anxiety Scores (DASS 21 ) Stress Scores (DASS 21 ) NS Total DASS Score

14 Cardiac Rehabilitation Comparisons Richardson 1 Audelin 2 Evans 3 Zecchin (2000) (2008) (2011) (2015) Study Characteristics USA USA UK Australia Years (10 years) (10 years) (14 years) (20 years) Age (years) Gender (Women; %) Diagnosis CABG CABG CTSX _ PCI PCI OTHER

15 Cardiac Rehabilitation Comparisons Richardson 1 Audelin 2 Evans 3 Zecchin (2000) (2008) (2011) (2015) Study Characteristics USA USA UK Australia Years (10 years) (10 years) (14 years) (20 years) Diabetes Hypertension Obesity Functional Capacity (VO 2 ) _ Smoking _ Hyperlipidaemia Lower Lipid levels Lower TC levels +

16 Cardiac Rehabilitation Comparisons Richardson 1 Audelin 4 Evans 5 Zecchin 6 (2000) (2008) (2011) (2015) Study Characteristics USA USA UK Australia Years (10 years) (10 years) (14 years) (20 years) Anti-Platelets _ Beta-Blockers _ ACE-I/ARB _ Lipid-Lowering _

17 Richardson 1 Audelin 4 Evans 5 Zecchin 6 (2000) (2008) (2011) (2015) Study Characteristics USA USA UK Australia Years (10 years) (10 years) (14 years) (20 years) Anti-Coagulants _ CCB _ Nitrates _ Digoxin _ Anti-Depressants _ Anti-Arrhythmics _

18 This study highlights the changing face of the cardiac patient entering into CR. Despite this study having some congruency with previous studies, novel findings including antidepressant, anti-arrhythmic, anti-coagulant, CCB and nitrate usage, and indicators of quality of life including depression, has not previously been evaluated for temporal trends in CR.

19 The study highlights the importance of data collection via a minimum dataset for outcome measures in CR. This study also has implications in regards to staff training and CR program redesign for future requirements to meet patient needs and demands. The increasing burden of disease as well as the increased usage of evidence-based interventions, especially cardio-active medications, define the patients accessing CR today and into the future.

20 1. L. Richardson et al. J Cardiopulmonary Rehabil 2000;20: M. Audelin, P. Savage and P. Ades. J Cardiopulmonary Rehabil and Prev. 2008;28: J. Evans, H. Bethell, S. Turner, G. Yadegarfar. J Cardiopulmonary Rehabil and Prev. 2011;31:

21

22 Time Interval (years) N = Age (years) * Gender (male; %) ** Day to presentation (median days) LVEF (%) * * p< ** p= 0.063

23 Time Interval (years) N = Age (years) * Gender (male; %) ** Day to presentation (median days) LVEF (%) * * p< ** p= 0.063

24 * p<0.001 Time Interval (years) Hyperlipidaemia (%) * Smoking * Diabetes (%) * BMI (kg/m 2 ) * Depression (%) * Hypertension (%) *

25 Rate of major coronary events for people aged years, by sex, Sources: AIHW National Hospital Morbidity Database and AIHW National Mortality Database.

26 Coronary artery bypass graft rates, by sex, to Source: AIHW National Hospital Morbidity Database.

27 Percutaneous coronary intervention rates, by sex, to Source: AIHW National Hospital Morbidity Database.

28 Supply of medicines with antithrombotic effect in the community, Sources: AIHW: Senes & Penm 2007 based on data from the Drug Utilisation Sub-Committee database, DoHA; DoHA 2009a; DoHA 2009b; and DoHA 2011.

29 Supply of medicines that lower blood pressure in the community, Sources: AIHW: Senes & Penm 2007 based on data from the Drug Utilisation Sub-Committee database, DoHA; DoHA 2009a; DoHA 2009b; and DoHA 2011.

30 Note: There is a break in the time series for statins because the defined daily dose (DDD) for some statins changed between 2006 and However, the DDD/1,000/day based on the new DDD are available from 2005 and therefore the break in the time series is shown here from Supply of serum-lipid-reducing agents in the community, Sources: AIHW: Senes & Penm 2007 based on data from the Drug Utilisation Sub-Committee database, DoHA; DoHA 2009a; DoHA 2009b; and DoHA 2011.

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