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Cardiac
Rehabilitation
20111Update
for
Primary
CareProvidersDouglass
A
Morrison,
MD,
PhDCardiac
Rehabilitation,
Medical
DirectorYakima
Regional
and
Yakima
Valley
MemorialHospitalsRehabilitation2To
restore
to
good
health
or
useful
life,through
therapy
and
education.Changing
our
own
behavior,for
better
healthChanging
BehaviorResistances3Therapy:
connotation
of
‘mental
illness’
Rehabilitation:
connotation
of
‘substanceabuse’
Personal
Responsibility
is
much
more
difficthan
blaming
No
one
can
rehabilitate
another;
most
of
thework
is
done
by
the
patient,
for
himself..Active
versus
Passive4Second
Person
versus
First
PersonIt
is
easier
to
tell
others
how
they
should
chathan
tochange
ourselves:
empathyCardiac
Rehabilitation
2011Bill
of
Fare5What
is
cardiac
rehabilitation?What
is
the
difference
between
primary
and
secondary
prevention?
Is
there
good
clinical
evidence
which
supports
the
efficacy
of
cardiarehabilitation?SurvivalMyocardial
infarct
(MI)
reductionStroke
(CVA)
preventionAvoidance
of
subsequent
bypass
surgery
(CABG)Reduced
repeat
stenting
(PCI)Reducedfrequency
of
hospitalizationCardiac
Rehabilitation
2011Bill
of
Fare
(2)6Does
the
evidence,
which
supports
the
use
of
cardiac
rehabilitationapply:In
the
‘reperfusion-era’
of
post
MI
care?To
the
elderly
(Medicare
population)?Women?Care-givers,
themselves?5.
In
your
personal,
and
professional
experience,
is
behavior
change:Easy,
i.e.
a
‘slam-dunk’?Impossible,
and
therefore,
not
even
worth
discussingPossible,
but
requiring
sustained
effortDefinition
of
Cardiac
Rehabilitati7
A
multi-component
intervention,
which
isdesigned
to:
Optimize
a
cardiac
patient"s
physical,psychological
and
social
function,
and
Stabilize,
slow,
or
even
reverse
theunderlying
atherosclerosis;
thereby
Reducing
the
morbidity
and
mortality
ofcoronary
artery
disease
(CAD).Physical
Activity
and
the
Prevention
of
CoronaHeart
Disease8
Meta-analysis
of
43
studies
from
world
literature
ofphysical
activity
andCAD
up
to
1987Objective
assessments
of
individual
activity,andof
CH
Attempt
to
infer
causal
relationship
based
on
criteriaAB
Hill
and
RothmanSequence:
activity
precedes
incidence
of
CHDConsistency
across
studiesStrength
of
associationGraded
across
multiple
levels
of
activityPlausibilityCoherenceSupported
by
biological
studiesPowell
et
al;
Ann
Rev
Public
Health1987;8:253Diet,
Exercise,
and
Smoking
Modificationafter
acute
coronary
syndrome
(ACS)9
18,809
patients
from
OASIS
5
prospectiverandomized
trial,
conducted
in
41
countries.
Most
patient
were
compliant
withaspirin
(96statins
(79%);
ACE-I/beta
blockers
(72%).
29%
did
not
follow
diet
or
exercise;
1/3
ofsmokers
persisted;
42%
did
either
diet
orexercise;
30%
did
both
diet
and
exercise.
MI
risk
reduced
significantly
by
diet,
exercand
smoking
cessation.Circulation
2010;121:750-758Cardiac
Rehabilitation:Contemporary
Era
and
Elderly
Population
601,099
Medicare
beneficiaries,
who
werehospitalized
for
coronary
conditions
and/orrevascularization
(PCI
or
CABG).
1-
5
year
mortalities
examined
using
multiplstatistical
methods
Only
12%
used
cardiac
rehabilitation
servicethey
averaged
24
sessions.
Mortality
rates
were
21-34%
lower
amongusersof
cardiac
rehabilitationDose-response
noted:
more
is
better.10Performance
Measures
for
PrimaryPrevention11Risk
factor
screeningDietary
counselingPhysical
activity
counselingSmoking
assessmentSmoking
cessation
interventionWeight/adiposity
assessmentWeight
managementBlood
pressure
measurementBlood
pressure
controlLipid
measurementLipid
controlGlobal
risk
assessmentAspirin
useCirculation
2009;120:1296-1336.Core
Components
of
Cardiac
Rehabilitation/Secondary
Prevention12EvaluationPatient
assessmentNutritionalWeight
managementBlood
pressureLipidsDiabetesSmokingPsychosocialPhysical
ActivityExercise
trainingInterventionCardiac
Rehabilitation
2011:
Summary
(1)
Neither
coronary
bypass
graft
surgery(CABG),
nor
percutaneous
coronaryintervention
(PCI),
with
or
without
stentshave
been
shown,
in
stable
patients,
toprevent
heart
attacks.13Cardiac
Rehabilitation
2011:
Summary
(2)14
Lipid
lowering
(primarily
with
statin
drugs
such
asLipitor,
Crestor,
or
Zocor);Aspirin;Beta-blockers;
andACE-inhibition;
have
all
been
shown
to
reduce
the
risk
of
futuremyocardial
infarction
(MI),
among
post
MI
patientsand
patients
with
stable
coronary
disease.
Compliance
can
be
enhanced
with
the
educationalcomponent
of
cardiac
rehabilitation.Cardiac
Rehabilitation
2011:
Summary
(3)15
Diet,
exercise,
and
smoking
cessation
have
beenshown
to
reduce
the
risk
of
subsequent
heart
attack.
Cardiac
rehabilitation,
in
a
large,
Medicare
studyhas
been
sown
to
be
associated
with
reducedlikelihood
of
heart
attack.
Getting
people
to
take
personal
responsibility
fortheir
own
health
involves
behavior
modification.It
is
not
easy,
but
we
can
all
do
it,
one
step
at-a-t‘When
we
study
biology,
we
are
life,contemplating
its
nature.’
George
Wald,
PhD
In
the
catheterization
lab,
orecholab,
oexercise
lab,
or
pulmonary
function
lab,We
are
contemplating
life’s
nature
And
we
are
applying
the
fruits
of
ourcontemplations
to
the
care
of
our
fellowhuman.We
follow
the
same
biological
principles.16Care-Giver,Heal
Thyself17
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