Cardiac Rehabilitation An Underutilized Class I Treatment for Cardiovascular Disease

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1 Cardiac Rehabilitation An Underutilized Class I Treatment for Cardiovascular Disease

2 What is Cardiac Rehabilitation? Cardiac rehabilitation is a comprehensive exercise, education, and behavior modification program designed to improve the physical and emotional condition of patients with heart disease. Prescribed to control symptoms, improve exercise tolerance, and improve overall quality of life. The primary goal of cardiac rehabilitation is to enable the participant to achieve his/her optimal physical, psychological, social and vocational functioning through exercise training and lifestyle change.

3 Core Components of Cardiac Rehabilitation Prescribed exercise to improve cardiovascular fitness without exceeding safe limits Education about heart disease along with counseling on ways to stabilize or reverse heart disease by improving risk factors Reduction/Cessation of Smoking Lipid Management Controlling High Blood Pressure Weight Loss/Control Improve/Manage Diabetes Increasing Physical Activity Encourage Healthy Eating Habits Improve Psychological Well Being

4 ACC/AHA Guideline Recommendations Referral to Cardiac Rehabilitation Class I indication in clinical guidelines for Myocardial Infarction Percutaneous Coronary Intervention Coronary Bypass Grafting Chronic stable angina Heart failure Peripheral arterial disease Cardiovascular prevention in women

5 Evidence Supporting the Guidelines Decreases Mortality at up to 5 years Post Participation Decreases Cardiovascular Events Improves Modifiable Risk Factors Improves Adherence with Preventive Medications Improves Function and Exercise Capacity Improves Quality of Life Fosters Lifelong Healthy Behaviors

6 Cardiac Rehabilitation and Survival in Older Coronary Patients Mortality Benefit of Cardiac Rehabilitation Methods Examined 1-5 year mortality in 601,099 Medicare beneficiaries hospitalized with diagnoses eligible to participate in cardiac rehabilitation in 1997 Used propensity based analysis of 70,040 matched pairs to compare up to 5 year mortality in those who participated in cardiac rehabilitation compared to those who did not Additionally, analysis was performed on a subgroup (n=17,298) of high-dose CR users (>25 sessions) and matched low dose users (1-24 sessions) Suaya JA, Stason WB, Ades PA, et al. Cardiac Rehabilitation and Survival in Older Coronary Patients. J. Am. Coll. Cardiol. 2009;54;25-33.

7 Cardiac Rehabilitation and Survival in Older Coronary Patients Results Overall Group (n=601,099) Crude Mortality Rate at 5 years: Relative risk reduction 59% Propensity Based Matched Pairs (70,040 pairs). Mortality at 1 year: users 2.2%; non-users 5.3% (relative risk reduction 58%) Mortality at 5 years: users 16.3%; non-users 24.6% (relative risk reduction 34%) Regression Modeling Mortality Rate at 5 years (adjusting for patient and hospital characteristics) 26% relative risk reduction Instrumental Variable Modeling Mortality Rate at 5 years: Users 29.8%; Non-users 37.8% (21% relative risk reduction) High Dose versus Low Dose (n=17,298) Mortality at 1 year: high dose 1.1%; low dose 2.6% (relative risk reduction 58%) Mortality at 5 years: high dose 14.0%; low dose 17.2% (relative risk reduction 19%)

8 Impact of Cardiac Rehabilitation on Mortality Following PCI A retrospective analysis from a prospectively collected registry of 2,395 consecutive patients who underwent PCI in Olmsted County, Minnesota, from 1994 to 2008 The association of cardiac rehabilitation with all-cause mortality, cardiac mortality, myocardial infarction, or revascularization was assessed Follow-up of 6.3 years 503 total deaths (199 cardiac) 394 total myocardial infarctions 755 total revascularization Geol K, Lennon RJ, Tilbury RT et al, Impact of Cardiac Rehabilitation on Mortality Following PCI. Circulation. 2011;123:

9 Impact of Cardiac Rehabilitation on Mortality Following PCI Participation in CR (40% (964 of 2395) of the cohort) was associated with a significant decrease in all-cause mortality (hazard ratio, 0.53 to 0.55; P<0.001). A trend toward decreased cardiac mortality was also observed in CR participants; No effect was observed for subsequent myocardial infarction or revascularization. Geol K, Lennon RJ, Tilbury RT et al, Impact of Cardiac Rehabilitation on Mortality Following PCI. Circulation. 2011;123:

10 Relationship between cardiac rehab & longterm risks of death & MI among elderly Medicare beneficiaries Dose dependent reduction in mortality and recurrent MI after cardiac rehabilitation Methods 30,161 elderly Medicare patients who attended at least 1 cardiac rehabilitation session between January 1, 2000, and December 31, Used a Cox proportional hazards model to estimate the relationship between the number of sessions attended and death and myocardial infarction (MI) at 4 years. The cumulative number of sessions was a time-dependent covariate. Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship Between Cardiac Rehabilitation and Long-Term Risks of Death and Myocardial Infarction Among Elderly Medicare Beneficiaries. Circulation. 121(2010); pp

11 Relationship between cardiac rehab & longterm risks of death & MI among elderly Medicare beneficiaries Results After adjustment for demographic characteristics, comorbid conditions, and subsequent hospitalization, patients who attended 36 sessions had a 14% lower risk of death (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.77 to 0.97) and a 12% lower risk of MI (HR, 0.88; 95% CI, 0.83 to 0.93) than those who attended 24 sessions 22% lower risk of death (HR, 0.78; 95% CI, 0.71 to 0.87) and a 23% lower risk of MI (HR, 0.77; 95% CI, 0.69 to 0.87) than those who attended 12 sessions 47% lower risk of death (HR, 0.53; 95% CI, 0.48 to 0.59) and a 31% lower risk of MI (HR, 0.69; 95% CI, 0.58 to 0.81) than those who attended 1 session Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship Between Cardiac Rehabilitation and Long-Term Risks of Death and Myocardial Infarction Among Elderly Medicare Beneficiaries. Circulation. 121(2010); pp

12 Relationship between cardiac rehab & long-term risks of death & MI among elderly Medicare beneficiaries Among Medicare beneficiaries, a strong dose-response relationship existed between the number of cardiac rehabilitation sessions and long-term outcomes. Attending all 36 sessions reimbursed by Medicare was associated with lower risks of death and MI at 4 years compared with attending fewer sessions. Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship Between Cardiac Rehabilitation and Long-Term Risks of Death and Myocardial Infarction Among Elderly Medicare Beneficiaries. Circulation. 121(2010); pp

13 Additional Studies Showing Reduction in Cardiac Endpoints after Cardiac Rehab Cochrane Database on Exercise-Based Rehabilitation for Coronary Artery Disease: Joliffe JA, Rees K, Taylor RS, et al. 2001;1:CD00180 Total mortality decreased by 13% to 27% Taylor RS, Brown A, Ebrahim S, et al. Am J Med 2004;116: Exercise based rehab was associated with lower all-cause (OR 0.80) and cardiac mortality (OR 0.74) Also lowered lipids, systolic blood pressure, smoking, QOL Clark AM, Hartling L, Vandermeet B. et al. Meta-analysis: secondary prevention programs for patients with coronary artery disease. Ann Intern Med 2005;143: Reduced recurrent MI by 17%, 47% mortality benefit at 2 years Agency for Healthcare Research and Quality (AHRQ) Technology Assessment Program. Randomized trials of secondary prevention programs in coronary artery disease: a systematic review. Rockville, MD: AHRQ, 2005 Decreased hospitalizations, recurrent MI, and mortality

14 Despite Evidence Showing Benefit, Cardiac Rehabilitation is Underutilized Of eligible patients, only 14-35% of heart attack survivors and approximately 31% of patients after CABG participate in cardiac rehabilitation Participation is lowest in women, minorities, socio-economically disadvantaged patients, and the elderly JA Suaya, DS Shepard, ST Normand, PA. Ades, J Prottas, WB Stason. Use of Cardiac Rehabilitation by Medicare Beneficiaries After Myocardial Infarction or Coronary Bypass Surgery. Circulation 2007;116;

15 Healthcare Team Interventions to Improve Participation in Cardiac Rehabilitation Use of quality improvement processes that incorporate the Referral to Cardiac Rehabilitation Performance Measures Facilitated referral processes to encourage participation Include referral to cardiac rehab in discharge orders Endorsement of benefit to patients by providers Mended Hearts chapters provide peer endorsement Provision of sufficient information to patient and cardiac rehabilitation program to allow enrollment

16 For More Information About Cardiac Rehabilitation:

17 References Core Components of Cardiac Rehabilitation Balady GJ, Williams MA, Ades PA, et al. Core Components of Cardiac Rehabilitation/Secondary Prevention Programs: 2007 Update: A Scientific Statement from the American Heart Association and AACVPR. Journal of Cardiopulmonary Rehabilitation and Prevention. 2007;27: Class I indication in Clinical Guidelines E.M. Antman, D.T. Anbe, P.W. Armstrong et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines on the Management of Patients with Acute Myocardial Infarction). J Am Coll Cardiol, 44 (2004), pp L. Anderson, C.D. Adams, E.M. Antman et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non STelevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, American College of Physicians, Society for Academic Emergency Medicine, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol, 50 (2007), pp. e1 e157. R.J. Gibbons, J. Abrams, K. Chatterjee et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients with Chronic Stable Angina). J Am Coll Cardiol, 14 (2003), pp GN Levine, ER Bates, JC Blackenship et al. ACCF/AHA/SCAI Guideline for Percutaneous Intervention. J Am Coll Cardiol, 24 (2011), pp LD Hillis, PK Smith, JL Anderson et al ACCF/AHA guideline for coronary artery bypass graft surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol, 124(2011), pp

18 References S.A. Hunt, W.T. Abraham, M.H. Chin et al. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol, 46 (2005), pp A.T. Hirsch, Z.J. Haskal, N.R. Hertzer et al. ACC/AHA guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary: a collaborative report from the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease). J Am Coll Cardiol, 47 (2006), pp L. Mosca, E.J. Benjamin, K. Berra, Effectiveness-based guidelines for the prevention of cardiovascular disease in women 2011 Update: a guideline from the American Heart Association. J Am Coll Cardiol, 57 (2011), pp Evidence Supporting the Guidelines N.K. Wenger. Current Status of Cardiac Rehabilitation. Journal of the American College of Cardiology. 51(2008), pp Cardiac Rehabilitation and Survival in Older Coronary Patients Suaya JA, Stason WB, Ades PA, et al. Cardiac Rehabilitation and Survival in Older Coronary Patients. J. Am. Coll. Cardiol. 2009;54; Impact of Cardiac Rehabilitation on Mortality Following PCI Geol K, Lennon RJ, Tilbury RT et al, Impact of Cardiac Rehabilitation on Mortality Following Percutaneous Coronary Intervention. Circulation. 2011;123:

19 References Relationship between cardiac rehab & long-term risks of death & MI among elderly Medicare beneficiaries Hammill BG, Curtis LH, Schulman KA, Whellan DJ. Relationship Between Cardiac Rehabilitation and Long-Term Risks of Death and Myocardial Infarction Among Elderly Medicare Beneficiaries. Circulation. 121(2010); pp Additional Studies Showing Reduction in Cardiac Endpoints after Cardiac Rehab Cochrane Database on Exercise-Based Rehabilitation for Coronary Artery Disease: Joliffe JA, Rees K, Taylor RS, et al. 2001;1:CD00180 Taylor RS, Brown A, Ebrahim S, et al. Am J Med 2004;116: Clark AM, Hartling L, Vandermeet B. et al. Meta-analysis: secondary prevention programs for patients with coronary artery disease. Ann Intern Med 2005;143: Agency for Healthcare Research and Quality (AHRQ) Technology Assessment Program. Randomized trials of secondary prevention programs in coronary artery disease: a systematic review. Rockville, MD: AHRQ, 2005 Despite Evidence Showing Benefit, Cardiac Rehabilitation is Underutilized JA Suaya, DS Shepard, ST Normand, PA. Ades, J Prottas, WB Stason. Use of Cardiac Rehabilitation by Medicare Beneficiaries After Myocardial Infarction or Coronary Bypass Surgery. Circulation 2007;116; Healthcare Team Interventions to Improve Participation in Cardiac Rehabilitation Thomas RJ, King M, Lui K, et al. AACVPR/ACCF/AHA 2010 update: performance measures on cardiac rehabilitation referral to cardiac rehabilitation/secondary prevention services. Circulation. 2010;122: Balady GJ, Ades PA, Bittner VA et al. Referral, Enrollment, and Delivery of Cardiac Rehabilitation/Secondary Prevention Programs at Clinical Centers and Beyond: A Presidential Advisory from the American Heart Association. Circulation :

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