1st Journal Reading

October 9th, 2019

Cleveland Clinic Journal of

Medicine (2018)

Cardiac rehabilitation:
A class 1 recommendation

Presented by: dr. Aulia Angraini

Supervised by: dr. Arnengsih Sp. KFR
Introduction

after heart surgery,

myocardial infarction, or
Class 1 coronary intervention
indication
Cardiac stable angina or peripheral
artery disease
Rehabilitat
ion (CR)
Class 2a Stable heart failure
indication

CR is still underutilized despite its demonstrated benefits

EXERCISE: SLOW TO BE ADOPTED

•WilliamHeberden: a patient
with angina pectoris who
“set himself a task of
sawing wood for half an
hour every day, and was
nearly cured
Before 1330s
•Mobilization and
•Extended bedrest were
encouraged for up to 6
weeks after a
cardiovascular event

1772s
EXERCISE: SLOW TO BE ADOPTED

1950s
• Levine’s
introduction
of up-to-
chair • Short daily
therapy walks

1940s

Over time, the link between a sedentary lifestyle and

cardiovascular disease was
studied and led to greater investigation into the benefits of exercise.
CARDIAC REHABILITATION:
COMPREHENSIVE RISK REDUCTION
Definition of Cardiac Rehabilitation
American
Association of • Provision of comprehensive long-term services
Cardiovascular involving medical evaluation, prescriptive exercise,
and Pulmonary cardiac risk-factor modification, education, counseling,
Rehabilitation and behavioral interventions.
(AACVPR )

USCenters • Physician-supervised program that furnishes

for Medicare physician-prescribed exercise, cardiac risk-factor
and Medicaid modification (including education, counseling, and
Services behavioral intervention), psychosocial assessment,
(CMS) outcomes assessment, and other items and services.
CARDIAC REHABILITATION:
COMPREHENSIVE RISK REDUCTION

Cardiac rehabilitation programs

Provide medically supervised exercise and patient education

Designed to improve cardiac health and functional status

reduce
disability to alleviate
Risk to improve
and rates activity
factors functional
of morbidity related
targeted capacity
and symptoms.
mortality
FROM HOSPITAL TO SELF-MAINTENANCE
 PHASES OF CARDIAC REHABILITATION
Phase 1 Inpatient Discussion with primary provider

Early mobilization, mild activity

Refferal
Phase 2 Outpatient Comprehensive secondary prevention model

Individualized treatment plan

Risk Modification
Psychosocial counseling
Phase 3 Maintanance Cardiac monitoring no longer needed

Independent continuatum of risk-factor modification

and exercise, with periodic physician evaluation
EXERCISE: MOSTLY SAFE, WITH PROVEN BENEFITS

Safety of cardiac rehabilitation iswell established, with alow riskof

major cardiovascular complications
• US study in the early 1980s of 167 CR programs found 1 cardiac
arrest for every 111,996 exercise hours, 1 myocardial infarction per
293,990 exercise hours, and 1 fatality per 783,972 exercise hours
Benefitsof cardiac rehabilitation arenumerous and substantial
• 2016 Cochrane review and meta-analysis of 63 RCT with 14,486
participants found a reduced rate of cardiovascular mortality, with a
number needed to treat of 37, and fewer hospital readmissions
EXERCISE: MOSTLY SAFE, WITH PROVEN BENEFITS

Reductions in mortality rates are dose-dependent

• Those who attended more sessions CR had a lower rate of morbidity

and death at 4 years, particularly if they participated in more than 11
sessions
EXERCISE: MOSTLY SAFE, WITH PROVEN BENEFITS

Is the overall mortality rate improved?

The2016 Cochranereview and meta-analysis: although
CRcontributed to improved cardiovascular mortality rates and
health-related quality of life, no significant reduction was detected in
the rate of death from all causes
Alarge cohort analysis: who had undergone CR found arelative
reduction in mortality rate of 58% at 1 year and 21% to 34% at 5
years, with elderly women gaining the most benefit.

HF-ACTION trial: exercise training for heart failure was associated

withreduced rates of all-causemortality or hospitalization and of
cardiovascular mortality or heart failure hospitalization
WHO SHOULD BE OFFERED CARDIAC REHABILITATION?
WHEN TO REFER

Ideally, referral for outpatient CR should take place

at the time of hospital discharge
• “cardiovascular continuum of care”
model that emphasizes a smooth
The AACVPR
transition from inpatient to outpatient
programs
US and Canadian • Within 1 to 4 weeks of the index event,
guideline with acceptable wait times up to 60 days
• within 24 hours of patient eligibility;
assessment for a CR program, is
In the United Kingdom
expected to be completed within 10
working days of referral
• Hospital discharge to CR program
In the United States
enrollment averages 35 days
WHEN TO REFER
REHABILITATION IS STILL UNDERUSED

Referral rates vary

1997 Medicare: referral rates National Cardiovascular

ofonly 14% after myocardial
infarction and 31% after
CABG
Data Registry between
2009 – 2017: the situation
had improved, with
areferral rate 60% for
patients undergoing PCI

Small Midwestern hospitals hadreferral rates

>80%,while major teaching hospitals and hospital
systems on the East Coast and the West Coast:<20%.
REHABILITATION IS STILL UNDERUSED

Referral rates vary

Other studies foundlower

referral rates for women and
patients with In UK, patients with heart failure
comorbiditiessuch as previous made uponly 5% of patientsin CR
CABG, diabetes, and heart
failure
REHABILITATION IS STILL UNDERUSED
REHABILITATION IS STILL UNDERUSED

Enrollment, completion rates even lower

Enrollmentwas 50% in the United Kingdom in 2016.

2015 US study: 58,269 older patients eligible for CR after AMI;62% were
referredfor CR at the time of discharge, butonly 23% of the total
attendedat least 1 session, and just5% of the total completed 36 or
moresessions.
BARRIERS, OPPORTUNITIES TO IMPROVE

Barriers

Weak
Lack of
endorsement Lack of
physician Female sex of
by the program
awareness and patients
prescribing availability
referral
provider
most modifiable factors
Lack of or
Low
Work-related limited
socioeconomic
hardship healthcare
status
insurance
BARRIERS, OPPORTUNITIES TO IMPROVE
Effort
Increasing physician awareness

Increase CR referral and participation include automated

order sets, increased caregiver education, early morning or
late evening classes, single-sex classes, home or mobile-
based exercise programs, parking and transportation
assistance

Lowering patientcopayments
THANK YOU
SLIDE CR AULIA
 Guidelines for Cardiac Rehabilitation
and Secondary Prevention Programs
Guideline 1.1 Recommendations for Stressing the Role of Intensive Secondary Prevention Thr
ough Intensive Risk Factor Reduction and Cardiac Rehabilitation
Class I
• All eligible patients with acute coronary syndrome or whose status is immediately post-coron
ary artery bypass surgery or post-PCI should be referred to a comprehensive outpatient cardi
ovascular rehabilitation program either before hospital discharge or during the first follow-u
p office visit (Level of Evidence: A).
• All eligible outpatients with the diagnosis of ACS, coronary artery bypass surgery, or PC I (Le
vel of Evidence : A) , chronic angina (Level of Evidence:B), and/or peripheral artery disease (L
evel of Evidence:A) within the past year should be referred to a comprehensive outpatient ca
rdio-vascular rehabilitation program.
• A home-based cardiac rehabilitation program can be substituted for a supervised, center-bas
ed program for low-risk patients (Level of Evidence:A).
Class Ila
• A comprehensive exercise-based outpat
ient cardiac rehabilitation program can
be safe and beneficial for clinically stabl
e outpatients with a history of heart fail
ure (Level of Evidence: B).
Absolute and Relative Contraindications to E
xercise Training
Absolute
 Recent change in the resting ECG suggesting significant ischemi
a, recent MI, or other acute cardiac event
 Unstable angina
 Uncontrolled cardiac arrhythmias
 Symptomatic severe aortic stenosis or other valvular disease
 Decompensated symptomatic heart failure
 Acute pulmonary embolus or pulmonary infarction
 Acute noncardiac disorder that may affect exercise performance
or may be aggravated by exercise (e.g., infection, thyrotoxicosi
s)
 Acute myocarditis or pericarditis
 Acute thrombophlebitis
 Physical disability that would preclude safe and adequate exerci
Relative.
 Electrolyte abnormalities
 Tachyarrhythmias or bradyarrhythmias
 High-degree atrioventricular block
 Atrial fibrillation with uncontrolled ventricular rate
 Hypertrophic obstructive cardiomyopathy with peak resti
ng left ventricular outflow gradient of >25 mmHg
 Known aortic dissection
 Severe resting arterial hypertension isystolic blood press
ure [BP] >200 mmHg and diastolic BP >110 mmHg)
 Mental impairment leading to inability to cooperate with t
esting
SECONDARY PREVENTION
Means unhealthy people that had been medicated or operated
but still has risks and stihh has chance to get worse
Weather primary prevention salected to healthy people with
risks
CR programs to become secondary prevention centers and
to expand the scope of patients cared for in CR. A center for t
he provision of individualized lifestyle and medical therapies, f
or monitoring symptoms and managing risk factors, for measu
ring outcomes and adjusting therapies to achieve guideline-ba
sed care—and one that can provide ongoing health educatio
n, as well as social and psychological support, to reduce morb
idity and mortality and improve quality of life to people across
the life span has real value in the future of health care. (AA
CVPR)
An important "hand-off" occurs at the time of patient discharge f
rom the hospital, when the patient leaves the acute care setting
and begins taking steps toward CR and restorative health in the
outpatient setting, under the supervision and guidance of health
care professionals. Unfortunately, this important step is often a
misstep, when prescribed therapies are not taken and follow-up
visits are delayed or even missed.12 13 These gaps in adherence to
the secondary treatment plan can occur for a variety of reasons, i
ncluding patient, provider, and health care system factors. 14-18
From the patient perspective, the time following hospitalization
for a CVD event is filled with concerns, questions, and confusio
n. Patients have been diagnosed with a serious heart condition
and have been prescribed an array of new therapies. Concerns
about costs and potential side effects, as well as uncertainty ab
out treatment benefits, may lead patients to avoid prescribed tr
eatments.
benefit Cardiac Rehabilitation not only increa
se maximum capacity

The benefits of cardiac rehabilitation go beyond risk reduction and i

nclude improved functional capacity, greater ease with activities of d
aily living and improved quality of life. 9 Patients receive structure and
support from the management team.
 6 weeks to start cardiac rehabilitation

Wound care — After discharge from the hospital, the patient is usually
given instructions about how to care for their chest and/or leg woun
ds. It is important to follow these instructions closely and to notify a
healthcare provider immediately if there are questions or concerns.
• Avoid heavy lifting and extremes of shoulder movement (eg, as i
n tennis, baseball, and golf) for six to eight weeks after surgery t
o allow for complete healing of the breast bone (sternum)
Interpretation Risk Factor

AACVPR. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs. 4thed. Champaign (IL): Human Kinetics. 2004
Phase I/ in patient stage

+ Assessment, education, counseling and 6 MWT (Phase I)