Kardiovaskuläre Erkrankungen ein Update für die Praxis, 22. Mai 2014 PD Dr. Matthias Wilhelm

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1 Bewegungsbasierte kardiale Rehabilitation als 3. Säule fit für die Zukunft? Matthias Wilhelm Cardiovascular Prevention, Rehabilitation & Sports Medicine University Clinic for Cardiology Interdisciplinary Center for Sports Medicine Conflicts of interest Biased in favour of Exercise is Medicine 1

2 Lifestyle and cardiovascular risk Family history Age Gender Sedentary lifestyle Smoking Dietary fat & sugar Depression Obesity Emotional stress Hypertension Inflammation Dyslipoproteinaemia Type II Diabetes Secondary prevention through comprehensive cardiac rehabilitation Sedentary lifestyle Physical activity rec. Smoking Smoking cessation Dietary fat & sugar Nutrition counselling Depression Emotional stress Psychosocial management Inflammation Obesity Weight control management Hypertension Type II Diabetes Dyslipoproteinaemia Optimal medical therapy

3 Heart 2012;98: Heart 2013;99:

4 to 1996 Reduction of total mortality 27% (OR % CI 0.54 to 0.98) to 2008 Reduction of total mortality 13% (RR % CI 0.75 to 0.99) Why does exercise based rehabilitation work/not work? 4

5 Exercise mitigates post MI myocardial remodeling, thus reducing the arrhythmogenic substrate («ACE inhibitor effect») After 15 years: More deaths related to cancer in the intervention group (by chance?) During year 1 to 3: Betablocker usage intervention 24.1%, control 15.4% (NS) Coronary mortality was 47.9% in the intervention group and 58.8% in the controls (P=0.04) which was due to the lower number of sudden deaths in the intervention group, 16.5%, compared with 28.9% in the controls (P=0.004). 5

6 What works in the long term? OR (95% CI) CABG 0.87 (0.65, 1.16) PCI 0.81 (0.49, 1.34) WMD (95% CI) Total cholesterol 0.37 ( 0.63, 0.11) LDL cholesterol 0.20 ( 0.53, 0.12) HDL cholesterol 0.05 ( 0.03, 0.14) Systolic BP 3.19 ( 5.44, 0.95) OR (95% CI) Smoking 0.64 (0.50, 0.83) Conversion from fatal to non fatal MI? improved myocardial revascularisation? protection against fatal dysrhythmias? improved cardiovascular risk factor profile? improved cardiovascular fitness? increased patient surveillance? 10 hours of exercise training in 6 to 16 sessions over 6 to 8 weeks 38 to 100 min/week Exercise training should be prescribed on an individualized approach. As general advice, recommend: 150 min/week, ideally 3 4 h/week Sub maximal endurance training, i.e., starting at 50% of maximal work load or VO2 max if available and gradually increasing till 70%. 6

7 The overall increase in fitness (0.52 METs) was only a third the mean estimate reported in a recent systematic review (1.55 METs). The exercise training volume prescribed was also only a third that reported in most international studies. These low training volumes and small increases in cardiorespiratory fitness may partially explain the reported inefficacy of UK cardiac rehabilitation to reduce patient mortality Intervall Training E. Zatopek: (400m HIGH, 200m LOW) * 100 (!!) 7

8 +46% 1.7 MET Circulation 2007; 115:3086 Zone III HF >130 bpm (>93% max.) % +41% 2.97 MET 8

9 «despite the existence of guidelines for cardiac rehabilitation for over 20 years, around 60% 70% of patients do not receive optimal secondary prevention» many clinicians have expressed doubts that long term behavioural change from time limited cardiac rehabilitation is realistic for patients with CHD. These concerns are then reflected in clinicians interactions with patients and referral behaviours. Conclusion Exercise based cardiac rehabilitation should be delivered as a secondary prevention program, including optimization of medical therapy Programs should include high quality exercise recommendations and therapy, delivered by exercise specialists Cardiac patients benefit most from supervised programs, followed by recommendations for homebased training to assure long term adherence to activity goals Referral strategies to CR programs have to be improved, especially for minorities Vielen Dank 9

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