Cardiac Rehabilitation: From the other side of the glass door No disclosures, no conflicts Charles X. Kim, MD, FACC, ABVM Objectives 1. Illustrate common CV benefits of CV rehab in real world practice. 2. Identify benefits of CV rehab on patient care and outcomes 3. Review and identify common CV scenarios that may require additional clinical information and communication Chicago, circa 1999 50 year old African American grandfather on the South Side of Chicago. Large anterior MI. EF 30%. Discharged home and given a few phone numbers with instructions that he should call around to arrange rehab. 1
Due to budget cuts, no cardiac rehabilitation at the hospital. Neither inpatient nor outpatient. Readmission was not a metric, so was not something that money was spent on reducing. It made sense in theory, but nobody would pay for it. Over the last 15 years Meta-analyses in 2004 and 2005: 20-47% mortality reduction with cardiac rehabilitation Taylor RS, et al. Am J Med 2004;116:682-92 Clark AM, et al. Ann Intern Med 2005;143:659-72. Over the last 5 years Large Medicare study of >600,000 patients: Patients who attended more than 25 cardiac rehabilitation sessions with >20% mortality reduction compared to those who attended less. Hammill BG, Curtis LH, Schulman KA, et al. Relationship between cardiac rehabilitation and long-term risks of death and myocardial infarction among elderly Medicare beneficiaries. Circulation 2010;121:63-70. 2
Current era, modern day Reimbursement to institutions tied into outcomes: readmissions, repeat procedures, cardiac events and death. With cardiac rehabilitation being linked to improved survival, the payers have finally gotten (more) behind the times. Thank you! Thank you for helping keep patients safe and improving their outcomes, quality of life and survival. From a Cardiologist perspective: How do we use cardiac rehabilitation in our clinic to improve our outpatient cardiology care? All of the following scenarios happen frequently and previously would have led to adverse outcomes Heart Failure Patients are often started on complex medical regimens in hospital that need adjusting when they go home. Gaining water weight and worsening exertional capacity as first signs early on. 3
Medication Side Effects After MI or PCI, a number of new medications: Dyspnea with Brilinta Fatigue with beta blockers Lightheadedness with various antihypertensives Myalgias with statins Blood Pressure Again, after hospitalization patients may be overmedicated or undermedicated on a new (to them) regimen. Being able to see heart rate and blood pressure under light and medium load can help us determine which medications to adjust. Heart Rate Sick sinus syndrome Atrial fibrillation Inappropriate heart rate response (either too high or too low) to correlate with symptoms. Angina Incompletely revascularized coronaries Adjustment of nitrates, calcium channel blockers and ranolazine. Identification of ischemic threshold in a safe and controlled manner. 4
Arrhythmia Exercise induced: Supraventricular tachycardia Ventricular tachycardia Atrial fibrillation Cardiovascular disease review Heart disease is different than heart disease is different than heart disease. Scenario #1 49 year old with anterior STEMI who got PCI of LAD. 49 yo with anterior STEMI How early did he get revascularized? How much of an infarct? EF and valves? Is there anything left still unrevascularized? 5
Scenario #2 60 year old with NSTEMI found to have chronic totally occluded RCA and EF 45%. 60 yo with NSTEMI and CTO RCA Is there viability in the RCA or is it infarcted? Are there currently exertional symptoms / ischemic threshold that you can glean from the admission / stress testing? Scenario #3 70 year old with aortic stenosis and CHF. 70 year old with AS and CHF Systolic or diastolic CHF? Was the CHF due to the valve (moderatelysevere AS or severe AS)? Is there an aortic aneurysm that might require more attention to blood pressures? 6
Scenario #4 85 year old with afib and CHF 85 yo with AF and CHF Rate vs. rhythm control? How good is the control? Was the CHF due to the AF? Was the EF determined in the setting of RVR? Is there underlying ischemia that would make heart rate control more important? Scenario #5 27 year old with HOCM and CHF 27 yo with HOCM and CHF Was the CHF due to the HOCM? Were there extenuating circumstances (like dehydration)? Has the HOCM been relieved (myectomy)? 7
Scenario #6 42 year old with severe cardiomyopathy, EF 15% and CHF 42 yo with cardiomyopathy and CHF Do you expect the CHF to improve? What is the timecourse of improvement you might expect? CAD vs tachycardia induced vs alcohol vs stress cardiomyopathy. General approach What is damaged and what s left at risk? What s been fixed and what s expected to improve? Last pitch: Who should drink water? If you have normal kidneys and NO hypertension, drink away. All others, there are caveats. Insulin and sugar analogy Diuretics and fluids 8
Cardiac rehabilitation 20-30% mortality reduction. The sicker the patient, the more the clinical benefit. Real point of access reduction in hospitalizations and increase in quality of life. Extremely important part of the clinical team on the front line and transition from sick to well. 9