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THE CARDIOLOGY CONNECTION

THE CARDIOLOGY CONNECTION GUIDELINES FOR PREVENTION OF DISEASE PROGRESSION Peter K. Shaw, MD, FACC October 12, 2005 The Problem CAD -- leading cause of death and disability in U.S. among men and women Huge numbers: In 1997: AMI diagnosis in 1.1 million people

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THE CARDIOLOGY CONNECTION

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  1. THE CARDIOLOGY CONNECTION GUIDELINES FOR PREVENTION OF DISEASE PROGRESSION Peter K. Shaw, MD, FACC October 12, 2005

  2. The Problem • CAD -- leading cause of death and disability in U.S. among men and women • Huge numbers: In 1997: • AMI diagnosis in 1.1 million people • > 0.8 million revascularization procedures • Prevention of subsequent events and enhancement of physical function in patients have immense impact

  3. Cardiac Rehabilitation • Before the mid-20th C., treatment of MI: • 3 weeks of bedrest • Out of work up to 6 months, if work was to be permitted • Little understanding about the pathophysiology, causes, appropriate treatment, and prevention of subsequent events • Chair therapy: a major and courageous breakthrough!

  4. Cardiac Rehabilitation-2 • Programs 1st developed in 1960s • Benefits of ambulation recognized • Safer in supervised environment than at home • Developed into highly structured, physician and nurse-supervised, ECG monitored programs • Focus primarily on exercise (as medicine) • Dosage • Frequency • Intensity

  5. Cardiac Rehabilitation-3 • Hospital stays for MI and ACS 3-5 days • Reduced deconditioning • However, reduced opportunity for patient education • Regular exercise and risk factor modification reduce morbidity and mortality of CHD • Cardiac Rehab: assessment and modification of risk factors--> Secondary-prevention centers

  6. Cardiac Rehabilitation-4 • Exercise after MI: reduced overall and cardiac causes of mortality • Decreased rates of subsequent coronary events and hospitalizations • More efficient and effective than individual physician care: most care providers: • not fully trained in cardiac rehab techniques • inadequate time for effective nutritional advice, weight mgmt, exercise prescription

  7. Cardiac Rehabilitation-5 • Appropriate subjects: • AMI • Coronary revascularization • Chronic stable angina pectoris • CHF • Post cardiac transplant • Goals: • Prevent disability • Prevent subsequent coronary events

  8. Exercise Training • Cardiac arrest: 1/112,000 patient-hours • Non-fatal MI: 1/294,000 patient-hours • Mortality: 1/784,000 patient-hours • Exercise capacity:(aerobic conditioning, 3x/wk, over 3 mo) • increase by 30-50% • peak O2 consumption inc. 15-20% • Subjective improvement in performance of ADLs (climbing stairs, carrying groceries) • Higher angina threshold due to lower HRxBPs product as a result of aerobic conditioning • Physiologic adaptations are both central (cardiac) and peripheral (skeletal muscle and vascular)

  9. The Bottom Line • Long-term mortality from CV and all causes (meta-analyses ‘70s-’80s) • Cardiac rehab w/ 25% reduction in overall and CV mortality over 3 years • Why? • Improved lipids • Improved coronary blood flow • Reduced obesity • Improved HR variability and autonomic tone • Increased fibrinolysis • Improvement in psychological factors • EXERCISE TRAINING IMPROVES FNL CAPACITY, REDUCES SXS IN PTS W/ CAD, & REDUCES OVERALL AND CV MORTALITY

  10. Cardiac Rehab in DM-2 • Ongoing drug therapy (insulin, oral hypoglycemic agents) and need for exercise-related dose adjustments • Techniques of self-monitoring have become essential to pursue effective and safe exercise rehabilitation • Complications (retinopathy, neuropathy, nephropathy) all affect exercise prescription • Higher prevalence of silent ischemia requires careful monitoring

  11. BENEFIT IN TYPE 2 DM • 59 DM2 pts (vs 36 age-matched non-DM controls) • 2 month program after acute coronary event • After program, improvement in exercise capacity lower in diabetic pts • In pts with DM, significant inverse relation btw FBS and change in peak VO2 • Thus, degree of glycemic control may have important implications in success of exercise rehabilitation in this cohort. • Verges, et al. Diabet Med. 2004 Aug:21 (8): 889-95

  12. RESULTS OF CARDIAC REHAB IN PTS WITH DM • In 2003 study, 26% of pts in a program at Boston Medical Ctr. had DM • 53% taking insulin &/or oral hypoglycemic medication • Greater risk profile, with higher prevalence of • hypertension -PVD • obesity -lower ex. Capacity • Initial Hgb A1C 8.4% • Fewer DM pts completed program (38% vs 48%) • exacerbation of medical problem (both cardiac and noncardiac) cause of dropout (29% vs. 18%) • Banzer et al., AmJCard 93 (1) 2004 Jan1 (81-84)

  13. APPROACH TO INVOLVEMENT OF DIABETIC PATIENT IN CARDIAC REHABILITATION • At intake appt, nurse card mgr reviews program guidelines with participant and involves PCP re: medication or diet adjustments before starting program • Classroom “Diabetes 101” review of diabetic guidelines for exercise • Participants encouraged to bring their own monitors (checked for accuracy by Program Monitor…+/- 20% acceptable accuracy) • BG monitored 15-30 min prior to exercise, and post-exercise for at least 3 sessions • If BG out of range, set protocol for intervention and consultation with PCP

  14. PROTOCOL

  15. TREATMENT OF HYPOGLYCEMIA • 50-100 mg/dl: 15 gm CHO; repeat BG testing after 15 minutes. May exercise when BG >120 mg/dl • <50 mg/dl: 30 gm CHO. Consider glucagon. Repeat BG testing after 15 minutes. Repeat CHO until BG >120 mg/dl and free of hypoglycemic sxs.

  16. VALUE OF CARDIAC REHABILITATION IN DM • The participant understands the importance of regular exercise as part of a comprehensive medical management strategy: “EXERCISE IS MEDICINE” • Establishes a habit and a rhythm of regular participation • Teaching safe methods of exercise • avoidance of pre- or post-exercise hypoglycemia • encourages choice of exercise appropriate to particular condition (neuropathy, retinopathy, nephropathy) • Encourages frequent testing as guide to safe approach • Participant understands diabetes as part of a collection of coronary risk factors--inspires patient to take responsibility for own medical condition

  17. Effects on Coronary Risk Factors • Lipids: 8-23% increase in HDL • Increase of chol/HDL = 5-26% • However, exercise training alone: • Minimal effect on LDL • 0-2% change in body wt at 3 months • -5% fat mass, +2% muscle mass • Improved glucose tolerance and less insulin resistance

  18. Exercise Prescription • Consider risk factors, age, functional status • Moderate to high intensity, 3-5x/wk, 25-45 min per session • Low caloric expenditure: 270-283 kcal/session, not likely to induce wt loss without dietary changes • Regimen of low-intensity, prolonged daily exercise (“high caloric training”) leads to greater fat loss than more intense briefer sessions • Important to include resistance training to minimize loss of muscle mass • Intervals of relatively intense exercise may lead to improvement in endothelium-dependent coronary vasodilation after 4 wks.

  19. Summary of Components and Goals • Initial history and physical examination • Control hypertension • Smoking cessation • Weight loss if BMI > 25 • DM control • Psychosocial adjustments • Physical activity counseling and exercise prescription and training • Enhance compliance: • Exercise: 50% at one year --anti-htn meds: 64% • lipid-lowering meds: 82% --f/u necessary after program

  20. Comprehensive Risk Reduction • Smoking: decision to stop is central • Unequivocal message from health professionals • Pick a date --Involve important others • Behavioral skills for coping with stress, possible use of bupropion &/or nicotine supplements • Followup • Hyperlipoproteinemia • Diet --Medications --Exercise --Followup

  21. Comprehensive Risk Reduction-2 • Weight-loss • May lead to 4-9% reduction when exercise w/ dietary intervention • Improved lipid levels, insulin resistance, BP, clotting abnormalities • Stimulus control (behavioral changes) • Self-monitoring • Social support (non-judgmental) • Daily calorie count and recording • 5-10% reduction in bw may be sufficient to improve lipids and insulin resistance

  22. Comprehensive Risk Reduction-3 • BP and DM-2 benefited by exercise training, weight loss, and improved diet • Self-monitoring of BP and DM important skills to learn; will help PCP management • Psychological Factors: • Cardiac rehab improves measures of • anxiety + emotional stress +self-confidence • depression +social isolation +quality-of-life

  23. Challenges • Extension of services to indigent and uninsured • Geographic issues, especially in rural states • Reaching appropriate patients: • In hospital screening and recruitment • Prioritize communication and involvement of cardiologist and PCP for referral and close followup • Individualize programs • to be appropriate for elderly, younger patients, the physically challenged, and the remotely situated • risk-factor modifications appropriate for each case • emphasize the payoff: physical, behavioral, and risk-factor changes that will lead to improved outcomes

  24. Helpful Resources • Philip A. Ades, MD, Cardiac Rehabilitation and Secondary Prevention of Coronary Heart Disease NEJM 2001; 345:892-902. • Wenger, NK et al, Cardiac rehabilitation: clinical practice guidelines, 1995 (AHCPR publication no. 96-0672) • DeBusk, RF, et alCase-mgmt system for coronary risk-factor modification after AMI Ann Int Med 1994: 120: 721-729 • Linden W, et alPsychosocial interv for pts w cad: meta-analysis Arch Int Med 1996; 156: 745-752

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