CARDIAC REHABILITATION

CARDIAC REHABILITATION William B. Nelson, MD, PhD, FACC Medical Director of Regions Hospital Cardiac Rehabilitation

WHAT IS CARDIAC REHABILITATION? Cardiac rehabilitation is a medically supervised program to help heart patients recover quickly and improve their overall physical, mental and social functioning. The goal is to stabilize, slow or even reverse the progression of cardiovascular disease, thereby reducing the risk of heart disease, another cardiac event or death. www.americanheart.org

HISTORY

HISTORY 1772 1 st to accurately describe angina pectoris Prescribed a six month exercise program consisting of 30 minutes of daily sawing wood for patient with a chest disorder Dr. William Heberden Certo, C.M. History of Cardiac Rehabilitation. Physical Therapy 1985; 65(12) 1793-1795

HISTORY Dr. Caleb Parry -Conducted experiments on sheep investigating circulation Found gritty substance in coronary arteries -Noted benefits of physical activity in his patients with chest pain - though organic diseases of the heart may be produced by violent exertions, it has been thought that they are counteracted by moderate bodily exercise Certo, C.M. History of Cardiac Rehabilitation. Physical Therapy 1985; 65(12) 1793-1795

HISTORY 1912- JAMA 1st to describe myocardial infarction Thrombogenic theory Expressed concern regarding physical exertion and the increased risk of ventricular aneurysm/rupture Dr. James Herrick Bed rest for 6-8 weeks Certo, C.M. History of Cardiac Rehabilitation. Physical Therapy 1985; 65(12) 1793-1795

HISTORY Bed rest became the norm treatment Physical activity restrictions post discharge No stair climbing for up to 1 year Follow up offered little advice on physical activity, stress management, or education about the cardiac disability Patients often never returned to work and were considered nonproductive members of society In the late 1930s the New York Employment Service found that 80% of individuals receiving disability had a cardiac diagnosis. Thus, they began work with the NYHA to evaluate these patients work capacity. Certo, C.M. History of Cardiac Rehabilitation. Physical Therapy 1985; 65(12) 1793-1795

HISTORY 1930 NYSES found that 80% of people receiving disability were cardiac patients Only 10% of those patients had attempted to retrain for new job Work Classification Units 1940 NYSES worked with NYHA to assess cardiac workers functional abilities Established Work Classification Units -Teaching hospitals -Rehabilitation centers -Community hospitals Certo, C.M. History of Cardiac Rehabilitation. Physical Therapy 1985; 65(12) 1793-1795

Certo, C.M. History of Cardiac Rehabilitation. Physical Therapy 1985; 65(12) 1793-1795 HISTORY Referred by physicians and employers Purpose of WCUs Job placement Educational experience for physicians Research Cardiologists performed testing Laboratory tests ECGs Masters Step test Work Classification Units Health care professionals interviewed patients to assess psychological capacity for work

HISTORY 1952 Questioned the need for prolonged bed rest following MI decreases functional capacity, saps morale, and provokes complications Raised clinical questions regarding management of CV disease Armchair treatment Dr. Bernard Lown Levine, S.A., Lown, B. Armchair treatment of acute coronary thrombosis. JAMA 1952; 148(16) 1365-1369.

HISTORY 1953-1953- 13th scientific session of the AHA meeting in Chicago - physicians must be ready to discard old dogma when they are proven false and accept new knowledge -Need for research on physical activity and its relationship with CAD Dr. Louis Katz Certo, C.M. History of Cardiac Rehabilitation. Physical Therapy 1985; 65(12) 1793-1795

HISTORY Dr. Paul Dudley White Founder of preventive cardiology Physician to Dwight Eisenhower following MI Believed in the positive effects of exercise -swimming -walking -golf Certo, C.M. History of Cardiac Rehabilitation. Physical Therapy 1985; 65(12) 1793-1795

HISTORY 1966 Dallas bed rest study 5 College students 3 weeks of bed rest Pre-Post exercise tests Decrease in cardiac output Decrease in maximal VO2 Certo, C.M. History of Cardiac Rehabilitation. Physical Therapy 1985; 65(12) 1793-1795

HISTORY Inpatient 1960 s Numerous studies demonstrate early activity following MI reduces adverse effects of bed rest without an increase in complications 14 step program of progressively increasing physical activity. Program included graded physical exercises, ADLs, and educational activities Led to faster recovery, decreased hospital stay, improved functional status at discharge, and earlier return to work Saltin, B., Bloomquist, G., Mitchell, J.H. et al. Response to exercise after bedrest and after training. Circulation 1968;38(Suppl VII): 1-78.

Certo, C.M. History of Cardiac Rehabilitation. Physical Therapy 1985; 65(12) 1793-1795 HISTORY Outpatient 1960 s Cleveland Cardiologist Incorporates physical exercise into a follow-up program at a local YMCA following hospital discharge. Physiological and psychological benefits without negative effect on morbidity or mortality Dr. Herman Hellerstein

Indications CURRENT PRACTICES Myocardial Infarction Stable Angina CABG Coronary angioplasty or stenting Heart or Lung transplant Heart valve repair/replacement Heart Failure* Cardiomyopathy* ACCF/AHA/ACP 2009 Competence and Training Statement: A Curriculum on Prevention of Cardiovascular Disease. Circulation. 2009;120:e100-e126

CURRENT PRACTICES Outpatient Up to 36 sessions of monitored exercise 2-3 one hour sessions per week Education sessions Diet & Nutritional counseling Medication reconciliation Emotional/Social support Staffed by Exercise Physiologists, RNs, Occupational Therapists, and Registered Dieticians

Education CURRENT PRACTICES Living well with heart disease Nutrition and Cholesterol: Food Choices and Your Cholesterol Labs Cardiac Medications Is it Time to Change Your Oil? Exercise & Equipment Heart Healthy Nutrition: How Do You Stack Up ABC S of CPR Hidden Fats: Where are They Hiding The Life Pump The Lifelines of the Heart: Your Coronary Arteries Stress Management Relaxation Techniques Blood Pressure Nutrition and Blood Pressure: Make a D.A.S.H. to Lower Yours ACCF/AHA/ACP 2009 Competence and Training Statement: A Curriculum on Prevention of Cardiovascular Disease. Circulation. 2009;120:e100-e126

CURRENT PRACTICES Goals Promote healthy lifestyle changes Increase understanding of heart disease Provide education on cardiac risks factors Increase exercise capacity Promote exercise independence Provide heart healthy nutritional information Encourage smoking cessation, if indicated Provide encouragement and support ACCF/AHA/ACP 2009 Competence and Training Statement: A Curriculum on Prevention of Cardiovascular Disease. Circulation. 2009; 120:e100-e126.

Benefits CURRENT PRACTICES Increased exercise capacity Decreased myocardial oxygen cost at any given submax workload Decreased HR and BP at given sub-max workload Increased exercise threshold for the onset of disease signs or symptoms (angina, claudication, ST depression) Modest reductions in resting SBP/DBP (5 7 mm Hg with endurance training) Increase in serum HDL Decreased serum triglycerides Reduced insulin needs, improved glucose tolerance Reduced platelet adhesiveness and aggregation Decreased anxiety and depression Enhanced feelings of well being ACSM s Guidelines for exercise testing and prescription, 7 th edition

Certo, C.M. History of Cardiac Rehabilitation. Physical Therapy 1985; 65(12) 1793-1795 CURRENT PRACTICES Improved Exercise Tolerance Tobacco Cessation Weight Management Nutritional Counseling Blood Pressure Management Diabetes Management Stress Management

Cardiac Rehab and Survival in Older Coronary Patients 601,099 Medicare patients with CAD/revascularization Mortality in CR users versus non users Mortality 21-34% lower in CR users at 5 years More sessions>25 associated with more benefit All Cause 5-year Cumulative Mortality Rates for Matched Pairs of CR Users and Nonusers by Demographic Characteristics Suaya, J.A., Stason, W.B., Ades, P.A. Cardiac Rehabilitation and survival in older coronary patients. JACC 2009; 54(1) 25-33.

Cardiac Rehab and Survival in Older Coronary Patients All Cause 5-year Cumulative Mortality Rates for Matched Pairs of CR Users and Nonusers by Demographic Characteristics Participant Groups # of Matched Pairs CR users Nonusers Difference *(p<0.001) All matched pairs- 5yr mortality 70,040 16.3% 24.6% 8.3%* Men 44,550 18.1% 25.2% 7.1%* Age 65-74 yrs 30,003 14.2% 19.9% 5.7%* Age 75-84 yrs 13,790 24.9% 34.7% 9.8%* Age 85+ yrs 757 47.3% 61.8% 14.5%* Women 25,490 14.2% 24.5% 10.4%* Age 65-74 yrs 15,678 11.5% 19.7% 8.2%* Age 75-84 yrs 9,135 17.2% 30.7% 13.4%* Age 85 + yrs 677 34.4% 53.9% 19.5%* Whites 67,569 16.6% 24.9% 8.3%* Nonwhites 2,471 18.1% 28.1% 9.9%* AMI 25,966 18.9% 30.9% 12.0%* PCI 14,679 14.7% 20.8% 6.1%* CABG 24,809 13.7% 19.0% 5.3%* Suaya, J.A., Stason, W.B., Ades, P.A. Cardiac Rehabilitation and survival in older coronary patients. JACC 2009; 54(1) 25-33.

Survival Cardiac Rehab Attendance vs. Non-Attendance Survival at 14 years was reviewed in 544 patients referred for cardiac rehab. 281 (52%) attended at least one session. Patients who attended <25% had double the mortality risk compared to those who attended 75% of sessions.

Hammill, B.G., Curtis, L.H., Schulman, K.A., et al. Relationship Between Cardiac Rehabilitation and Long Term Risk of Death and Myocardial Infarction Among Elderly Medicare Beneficiaries. Circulation 2010; 121:63-70 RESEARCH Relationship between Cardiac Rehabilitation and Long Term Risk of Death and MI Among Elderly Medicare Beneficiaries 30,161 Medicare patients Is there a dose response curve for cardiac rehab and risk? Evaluated MI and death versus number of sessions attended

Rehab Sessions Attended Hammill, B.G., Curtis, L.H., Schulman, K.A., et al. Relationship Between Cardiac Rehabilitation and Long Term Risk of Death and Myocardial Infarction Among Elderly Medicare Beneficiaries. Circulation 2010; 121:63-70 RESEARCH Relationship between Cardiac Rehabilitation and Long Term Risk of Death and MI Among Elderly Medicare Beneficiaries

Cumulative Incidence of Death Hammill, B.G., Curtis, L.H., Schulman, K.A., et al. Relationship Between Cardiac Rehabilitation and Long Term Risk of Death and Myocardial Infarction Among Elderly Medicare Beneficiaries. Circulation 2010; 121:63-70 RESEARCH Relationship between Cardiac Rehabilitation and Long Term Risk of Death and MI Among Elderly Medicare Beneficiaries

Relationship between Cardiac Rehabilitation and Long Term Risk of Death and MI Among Elderly Medicare Beneficiaries Pts that attended<12 sessions had the highest risk of MI or death at 4 years Pts that attended 36 sessions had a 58% reduction in death at 4 years compared to those that only attended one session A dose response relationship was seen, the more sessions attended, the lower the risk Hammill, B.G., Curtis, L.H., Schulman, K.A., et al. Relationship Between Cardiac Hammill, B.G., Curtis, Rehabilitation L.H., Schulman, and Long K.A., Term et al. Risk Relationship of Death Between and Myocardial Cardiac Infarction Rehabilitation Among and Long Term Risk of Death and Elderly Medicare Beneficiaries. Myocardial Circulation Infarction 2010; Among 121:63-70 Elderly Medicare Beneficiaries. Circulation 2010; 121:63-70

Comparison with ACE Inhibitors or Beta-Blockers ACE Inhibitor 5 long term ACE randomized ACE trials vs. placebo post MI (n-5966) Mortality 0.74 (0.66-0.83) Readmission 0.73 (0.63-0.85) The Lancet 2000;355:1575-1581 Beta Blocker OPTIMIZE-HF trial; Beta-blocker vs. placebo in 7154 HF patients at one year. Mortality Readmission 0.77 0.89 (0.68-0.87) (0.8-0.99) J Am Coll Cardiol 2009;53:184-192

Survival, Coronary Intervention, and Readmission Rates 5886 patients (Male 80%; Age ~ 60) referred for rehab after angiography. Group differences include more CABG in the completers and more PCI in those not completing or never enrolled.

Cardiac Rehab and Heart Failure Exercise tolerance is often reduced in HF patients. In recent years exercise training has emerged as a therapeutic treatment for heart failure. Recent studies have demonstrated that exercise in this population can be both safe and beneficial.

HF ACTION Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training STUDY 2,331 Patients with LVEF < 35% and NYHA class II to IV symptoms Randomized into two groups Usual Care Optimal medical therapy Recommendation of regular physical activity Exercise Training (n=1172) Optimal medical therapy 36 supervised exercise sessions at 3x per week Up to 35 minutes at 60-70% HRreserve Following the structured exercise program patients were instructed to exercise 5x per week Whellan, D.J., O Connor, C.M., Lee, K.L., et al; HF-ACTION Trial Investigators. Heart Failure and a controlled trial investigating outcomes of exercise training: design and rationale. Am Heart Journal. 2007; 153(2)201-211.

HF ACTION Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training HEALTH STATUS Kansas City Cardiomyopathy Questionnaire(KCCQ) 23 item questionnaire Patient reported health status Self administered at baseline clinic visit, at 3 month intervals for the first 12 months, and annually for up to 4 years Change in cardiopulmonary exercise test time, and change in peak oxygen consumption during exercise test, and change in 6 min walk distance Flynn, K.E., Pina, I.L., Whellan, D.J., et al. Effects of exercise training on health status inpatients with chronic heart failure:hf-action randominzed controlled trial. JAMA. 2009; 301(14)1451-1459.

HF ACTION Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training Change in 6 minute walk and cardiopulmonary exercise test results Usual Care Median(IQR) Exercise Training Median(IQR) P value Baseline to 3 mo 6 min walk distance, m cardiopulmonary exercise time 5 (-28 to 37) meters further 20 (-15 to 57) meters further 0.3 (0.6 to 1.4) minutes longer 1.5 (0.3 to 3.0) minutes longer <.001 <.001 Peak oxygen consumption, ml/kg/min Baseline to 12 mo 6 min walk distance, m cardiopulmonary exercise time Increase of 0.2 (-1.2 to 1.4) ml/kg/min Increase of 0.6 (-0.7 to 2.3) ml/kg/min 12(-30 to 55) meters further 13 (-28 to 61) meters further 0.2(-1.0 to 1.7) minutes longer 1.5 (0 to 3.2) minutes longer <.001 0.26 <.001 Peak oxygen consumption, ml/kg/min 0.1(-1.5 to 1.8) ml/kg/min 0.7(-1.0 to 2.5) ml/kg/min <.001

Safety and Efficacy O Connor, C.M., Whellen, D.J., Lee, K.L. et al. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randominzed controlled trial. JAMA. 2009; 301(14)1439-1450. RESEARCH HF ACTION Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training

Safety and Efficacy O Connor, C.M., Whellen, D.J., Lee, K.L. et al. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randominzed controlled trial. JAMA. 2009; 301(14)1439-1450. RESEARCH HF-ACTION- Safety HF ACTION and Efficacy Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training

Safety and Efficacy O Connor, C.M., Whellen, D.J., Lee, K.L. et al. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randominzed controlled trial. JAMA. 2009; 301(14)1439-1450. RESEARCH HF ACTION Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training

Safety and Efficacy O Connor, C.M., Whellen, D.J., Lee, K.L. et al. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randominzed controlled trial. JAMA. 2009; 301(14)1439-1450. RESEARCH HF ACTION Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training

HF ACTION Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training Cardiac rehab is safe. Modest persistent improvements in V02, GXT time and KCCQ No difference in mortality / hospitalization. CR was associated with a modest significant reduction in mortality and hospitalization (After adjusting for prognostic prediction of primary endpoint).

REIMBURSEMENT Cardiac Rehabilitation for Heart Failure 2014 CMS Approves Payment for Chronic CHF with LVEF < 35% NYHA Class II-IV Optimal heart failure treatment for 6 weeks No procedures or hospitalizations for CHF for 6 months

The Dose Response of Cardiac Rehabilitation A review of 30-day and one-year readmission rates, as well as mortality in HealthPartners patients according to cardiac rehab attendance.

Regions Cardiac Rehab Cohort Supported by a Discovery Grant from the HealthPartners Institute for Education and Research All HealthPartners patients referred for outpatient cardiac rehab from 1/1/2006 through 12/31/2007 were initially included (402 patients). Patients not assigned to 18, 24, or 36 sessions were excluded (55 patients). Remaining cohort of 347 patients.

Patient Information RESEARCH Patient Information Regions Cardiac Rehab Cohort Characteristics Race Referral Dx: Age = 64±12 years Caucasian = 86% Angina = 41% Male = 68% African American = 6% S/P Cardiac Procedures = 28% Smokers = 8% (39%?) Asian = 2% Acute MI = 26% BMI = 31±6 Hispanic = <1% CHF = 3% SBP = 130±20 American Indian = <1% Other Reasons = 2% DBP = 72±12 Unknown = 5% GFR = 64±14 LDL = 96±41 HDL = 43±12 Triglycerides = 142±83 HgB A1c =.6±1.4

Differences Between the Sessions Assigned Groups RESEARCH Regions Cardiac Rehab Cohort 18 Sessions 24 Sessions 36 Sessions p-value Patients 136 95 116 Age 62±11 65±11 66±12 0.01 Caucasian 87% 94% 79% 0.01 African American 4% 1% 11% 0.005 Angina 56% 49% 16% <0.001 Cardiac Procedures 21% 26% 39% 0.005 CHF <1% 0% 8% 0.001 BMI 30.1±6 33.3±6.9 29.9±5.8 0.02 GFR 67±11 64±13 61±17 0.01 LDL 101±42 104±46 85±34 0.002

Primary Finding of the Study: Regions Cardiac Rehab Cohort Better Attendance = Readmission

Primary Finding Regions of Cardiac the Study: Rehab Cohort Controlling for age, race, sex, and rehab sessions assigned at one year, each additional session of cardiac rehab was associated with a: 1.75% lower incidence of cardiac readmission (p-value =0.01) 2.0% lower incidence of all cause readmission (p-value = 0.001)

Regions Cardiac Rehab Cohort Per-Person Readmission Rates According to the Number of Sessions 0.2 0.15 0.1 0.05 30-Day Readmission Rates According to Number of Sessions Prescribed Prescribed 0 There was no statistically significant difference in 30-day readmission rates between the groups. Patients assigned to 36 sessions had significantly higher cardiac and all cause readmission rates at one-year compared to the other two groups. 1 0.8 0.6 0.4 0.2 30-day Cardiac Readmission 18 Sessions 24 Sessions 36 Sessions 30-day All Cause Readmission One-Year Readmission Rates According to Number of Sessions Prescribed 0 1-year Cardiac Readmission 1-year All Cause Readmission 18 Sessions 24 Sessions 36 Sessions

Regions Cardiac Rehab Cohort Per-Person 1 0.9 Readmission for 0.8 0.7 Perfect Attendance vs. 0.6 0.5 0.4 Non-perfect 0.3 0.2 Attendance 0.1 0 Patients with perfect attendance, regardless of number of sessions prescribed, had significantly lower cardiac and all cause readmission. 1.2 1 Per-Person Cardiac Readmission by Attendance 18 Sessions 24 Sessions 36 Sessions Perfect Cardiac Not Perfect Cardiac Per-Person All Cause Readmission by Attendance 0.8 0.6 0.4 0.2 0 18 Sessions 24 Sessions 36 Sessions Perfect All Cause Not Perfect All Cause

Regions Cardiac Rehab Cohort Mortality 0% At 30 days 1.7% At 1 year No statistical relationship between death and rehab attendance in our cohort.

Regions Cardiac Rehab Cohort Secondary Finding Per-Person Readmission Rates On average, controlling for age, sex, adherence, and number of rehab sessions assigned, African Americans have an 80% higher incidence of cardiac readmission than whites (p-value = 0.01). 1.15 0.63 1.35 Why? Statistical Differences Smoking = 0.05 GFR = 0.004 HgB A1c = 0.0012 0.52 1-YEAR CARDIAC Caucasian African American 1-YEAR ALL CAUSE

Key Points RESEARCH Regions Cardiac Rehab Cohort Cardiac rehab attendance is associated with improved outcomes In the Regions cohort, each additional session of rehab attended was associated with significant reductions in cardiac and all cause readmission when controlling for age, sex, race, and number of rehab sessions assigned. Perfect attendance, regardless of number of sessions assigned, is associated with significant reductions in cardiac and all cause readmission compared to those with missed sessions. Reinforcing smoking cessation, blood pressure management and salt monitoring, and diabetes management in African Americans may have a positive impact on their readmission rates.

What s the right amount of exercise? DOI:10.3810/psm.2011.09.1933

Do Ultra-Endurance Events Affect the Heart?

High Intensity Interval Training Why offer HIIT?

High Intensity Interval Training Enhanced training effect Greater improvement in VO2 peak Greater improvement in endothelial function Greater improvement in anaerobic threshold Increased patient confidence to be active Greater improvement in exercise capacity than moderate intensity exercise. Provides controlled overload of the O2 transport system, microcirculation, skeletal muscle metabolic apparatus CHF patients: found reverse left ventricular remodeling. No change with MIT. LV contractile function increased Improved endothelial function, reductions in atherosclerosis, better calcium regulation, higher shear stress: possible explanations. 25% decrease in all-cause mortality for each 1 MET improvement in fitness (at 1 year)

High Intensity Interval Training HIIT 80-90% + of capacity RPE 15-18 Work rate adjusted each session based on individual HR response. MIT 40-70% of capacity RPE 11-14

High Intensity Interval Training Variables in Prescription Mode of exercise Intensity Duration Intervals per session Progression HIIT sessions per week Exclusion Criteria Patient refusal Impaired cognition Language barrier Musculoskeletal limitations Angina with MIT (initial exclusion)

High Intensity Interval Training

High Intensity Interval Training Program Format > 3 weeks post MI or PCI > 4 weeks post surgery Run in period Attend at least 4 out of first 6 exercise sessions 1-2 weeks of MIT GXT- maximal exertion 30 days post event 2-3 intervals of 30-60s of RPE 16-18 1-5 minutes of MIT Progress to 5 intervals of 1-2+ minutes of RPE 16-18

Medication Adherence Patients hospitalized with MI from 1997-2006 n= 292 3 classes of medications ACE inhibitors (or ARB) Beta blockers Statins Medication adherence decreases progressively over time Shah, N.D. Long-term medication adherence after myocardial infarction: Experience of a community. AJM 2009; 122 (10) 961.e7-961.e13.

Medication Adherence and CR Cardiac rehab was the sole independent predictor or improved medication adherence in this study. Change in adherence among CR users vs non users statins (p=0.002) beta blockers (p=0.012) ACE inhibitors/arb (P=0.002) Shah, N.D. Long-term medication adherence after myocardial infarction: Experience of a community. AJM 2009; 122 (10) 961.e7-961.e13.

Benefits of Cardiac Rehab Is it the Cardiac Rehab? The Medical Compliance? Both?

Cardiac Rehab and Emotions Depression and Heart Disease Patients who drop out of cardiac rehab had higher baseline depression/anxiety scores and lower quality of life scores Patients who complete cardiac rehab show improvements in depression, anxiety and quality of life

Lavie, C.J., Milani, R.V. Prevalence of Hostility in Young Coronary Artery Disease Patients and Effects of Cardiac Rehabilitation and Exercise Training. Mayo Clinic Proceedings 2005; 80(3):335-342. RESEARCH Cardiac Rehab and Emotions Young CAD Patients and Hostility There is significant change in hostility pre and post rehab in all ages. Young CAD patients <50 years old have a statistically higher prevalence of hostility symptoms when compared to patients >65 years old

Barriers Challenges Referral According to the AHAs Get With the Guidelines, only 56% of eligible patients are referred for cardiac rehab. Adherence In the Study from Martin et al. (Circulation 2012;126:677-687) less than 50% of patients referred for cardiac rehab completed cardiac rehab, with the majority of these patients never enrolling. Cardiac Rehab Challenges

Referrals to Cardiac Rehab 100% 75% 74% 50% 42% 58% 53% 47% 25% 26% 0% PCI MI CABG Not Referred Referred Brown, T.M., Hernandez, A.F., Bittner, V. et al. Predictors of cardiac rehabilitation referral in coronary artery disease patients. JACC 2009; 54(6) 515-21.

Barriers to Participation Younger Male STEMI Participants more likely to be: PCI or CABG Ability to drive A post high school education Perceive their physician recommends cardiac rehab Non-Participants more likely to be: Diabetic Prior MI Lower income Downplay the seriousness of their illness 1.Copper, A.F., Jackson, G., Weinman, J. et al. Factors associated with cardiac rehabilitation attendance: a systematic review of the literature. Clinical Rehabilitation 2002; 16:541-552. 2. Dunlay, S.M., Witt, B.J., Allison, T.G., et al. Barriers to participation in cardiac rehabilitation. American Heart Journal 2009; 158(5) 854-9.

CR participation by strength of physicians recommendation 226 consecutive patients hospitalized for MI or CABG Investigated a variety of factors that predict outpatient cardiac rehab participation Patients rated the strength of their primary physicians recommendations regarding CR 1 No recommendation / Not mentioned. 2 3 4 Moderately Supportive of CR 5 Strong recommendation 1.8% Participation Rate (P<0.0001) 66% Participation Rate

CARDIAC REHABILITATION Reassurance Cardiac Rehabilitation Tobacco Cessation Medication Importance HIIT Telemedicine / Mobile Rehab

REFERENCES Hammill, B.G., Curtis, L.H., Schulman, K.A., et al. Relationship Between Cardiac Rehabilitation and Long Term Risk of Death and Myocardial Infarction Among Elderly Medicare Beneficiaries. Circulation 2010; 121:63-70 Suaya, J.A., Stason, W.B., Ades, P.A. Cardiac Rehabilitation and survival in older coronary patients. JACC 2009; 54(1) 25-33. ACCF/AHA/ACP 2009 Competence and Training Statement: A Curriculum on Prevention of Cardiovascular Disease. Circulation 2009; 120: e100-e126. Certo, C.M. History of Cardiac Rehabilitation. Physical Therapy 1985; 65(12) 1793-1795. Levine, S.A., Lown, B. Armchair treatment of acute coronary thrombosis. JAMA 1952; 148(16) 1365-1369. Saltin, B., Bloomquist, G., Mitchell, J.H. et al. Response to exercise after bedrest and after training. Circulation 1968;38(Suppl VII): 1-78 Whellan, D.J., O Connor, C.M., Lee, K.L., et al; HF-ACTION Trial Investigators. Heart Failure and a controlled trial investigating outcomes of exercise training: design and rationale. Am Heart Journal. 2007; 153(2)201-211. Wroblewski AP, Amati F, Smiley MA, et al. Chronic exercise preserves lean muscle mass in masters athletes. DOI: 10.3810/psm.2011.09.1933 Flynn, K.E., Pina, I.L., Whellan, D.J., et al. Effects of exercise training on health status inpatients with chronic heart failure:hf-action randominzed controlled trial. JAMA. 2009; 301(14)1451-1459. O Connor, C.M., Whellen, D.J., Lee, K.L. et al. Efficacy and safety of exercise training in patients with chronic heart failure:hf-action randominzed controlled trial. JAMA. 2009; 301(14)1439-1450. Dunlay, S.M., Witt, B.J., Allison, T.G., et al. Barriers to participation in cardiac rehabilitation. American Heart Journal 2009; 158(5) 854-9. Brown, T.M., Hernandez, A.F., Bittner, V. et al. Predictors of cardiac rehabilitation referral in coronary artery disease patients. JACC 2009; 54(6) 515-21. Shah, N.D. et al. Long-term medication adherence after myocardial infarction: Experience of a community. AJM 2009; 122(10) 961.e7-961.e13. Cooper, A.F., Jackson, G., Weinman, J. et al. Factors associated with cardiac rehabilitation attendance: a systematic review of the literature. Clinical Rehabilitation 2002; 16:541-552. Ades, P.A. et al. Predictors of Cardiac Rehabilitation Participation in Older Coronary Patients. Arch Intern Med 1992; 152, 1033-1035. Schnor P, O Keefe JH, Marott JL, et al. Dose of jogging and long-term mortality; The Copenhagen City Heart Study. J Am Coll Cardiol 2015;65:411-419 Gerche AL, Burns AT, Mooney DJ, et al. Exercise-induced right ventricular dysfunction and structural remodeling in endurance athletes. European Heart Journal 2012:33:998-1006