James A. Stone BPHE, BA, MSc, MD, PhD, FRCPC, FAACVPR, FACC Clinical Professor of Medicine, University of Calgary Total Cardiology, Calgary
Acknowledgements and Disclosures Acknowledgements Jacques Genest and Rob Welch National CPG Committee Memberships All of you! Disclosures No Current Industry/Government Funding National CPG Committee Memberships Canadian Diabetes Association 2013 Canadian Cardiac Rehabilitation Cardiac Rehabilitation (Chair) Canadian Hypertension Education Program C-CHANGE (Canadian Cardiovascular HArmonization of National Guidelines Endeavour) (Chair) CCS Dyslipidemia 2102 CCS Smoking Cessation 2011 CCS Committee on Chronic Stable Angina CCS Committee on Refractory Angina Physical Activity for Adults 2011 Physical Activity for Persons with Spinal Cord Dysfunction (Chair) 2011
Cardiac rehabilitation: 1. Improves CAD outcomes 2. No effect on CAD outcomes 3. Is primarily an exercise program 4. Is not cost-effective 5. Is over-utilized in Canada
Something Old,
Something Old "If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health. Hippocrates 460-377 BC
Something Old Superior doctors prevent the disease Mediocre doctors treat the disease before evident Inferior doctors treat the full blown disease Huang Dee: Nai-Chang (2600 BC. 1st Chinese Medical text)
Something Old 10 Studies; N=4347 JAMA 1988;260:945-950
Something Old < 5 METs 5-8 METs > 8 METs Circulation. 2002;106:666-671
Something Old 48 Trials 8940 patients Am J Med. 2004;116:682 692
Something New Cochrane Review 2011 47 studies: 10,794 patients Total Mortality:.87 CI.75-.99 63 Studies; N=21295 Cardiac Mortality:.74 CI.63-.87 One year Readmission:.69 CI.51-.93 Heran et al., Cochrane Database Syst Rev 2011; Jul 6.
Something New 34 RCTs; N = 6,111
N=601,099 Something New Suaya JA, Stason WB, Ades PA, et al. J Am Coll Cardiol. 2009; 54:25-33,
Something New N=5886 Clinical Variables 1. Age 2. Sex 3. Ejection fraction 4. Chronic obstructive pulmonary disease 5. Cerebrovascular disease 6. Elevated creatinine 7. Congestive heart failure 8. Dialysis 9. Hypertension 10. Hyperlipidemia 11. Diabetes mellitus 12. Presence of malignancy 13. Current smoking status 14. Former smoking status 15. Prior myocardial infarction 16. Prior percutaneous coronary intervention 17. Prior coronary artery bypass grafting [CABG] 18. Peripheral vascular disease 19. Liver or gastrointestinal disease 20. Severity of CAD (Duke jeopardy score) 21. Treatment strategy (percutaneous coronary intervention or CABG within 1 year of referral)
Something New Martin BJ et al. Circulation 2012
Something New Eur J Cardiovasc Prev Rehab 2009;16:102-113
Something New
Something New Int J Cardiol 2011;27:355-356
Something New In Press: Mayo Clin Proceed 2013
Something New
Cardiac rehabilitation: 1. Is proven to be cost-effective 2. Is cost-ineffective 3. Is cost-saving 4. Is just a touchy feely kumbaya program
Something Old and New Cost-Effectiveness Potentially cost-saving 1 Highly cost-effective 2-4 < 20,000 per QALY 1. Brown et al 2003 2. Oldridge et al 2008, 2005, 1998 3. Wong et al., 2012 4. CWIC 2013
Something Borrowed CMAJ Oct 2011
Something Borrowed Acronym for Secondary Prevention Stone JA et al. 2009
Cardiac rehabilitation: 1. Has a high attendance rate. 2. Has a high completion rate 3. Is attended more by women 4. Programs mostly serve males
Referrals Cardiac Rehabilitation Something Blue Under Review JACC
Referrals Cardiac Rehabilitation Something Blue Under Review JACC
Something Blue Waiting Times D/C - 65.6 ± 88.4 days Referral - 40.1 ± 73.9 days
Something Blue (or not) Can J Cardiol: 2011
Summary Systematic process-oriented care Treatment target driven Minimizes vascular oxidative stress Maximizing cardiometabolic fitness Reduces recurrent adverse CAD events Yes it does! Principle elements of chronic disease care Patient empowerment
Summary Something Old Something New Something Borrowed Something Blue