Cardiac Rehabilitation Its Not Just About Exercise

1
Cardiac RehabilitationIts Not Just About
Exercise

• Charles Dennis, MD
• Virtua Health
• The Cardiology Group, PC

2
Faculty Disclosure

• Financial Disclosure
• None
• Unlabelled/Unapproved Uses Disclosure
• None

3
History

• Bed rest as treatment for acute myocardial
  infarction
• Physical effects of 7 days of bed rest
• 40 decrease in lean muscle mass
• 70 decrease in peak aerobic capacity
• Intravascular volume depletion
• Increased vagal tone
• Physical reconditioning was required to regain
  sufficient strength and endurance for ADL

4
Contemporary Clinical Management

• Early diagnosis and rapid revascularization of
  myocardial infarction and unstable angina
• Shortened hospitalizations for CABG patients
• Early mobilization and discharge for most
  coronary patients
• Minimal loss of physical conditioning

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The Premise for Cardiac Rehab Has Changed

• Physical reconditioning is less important
• Exercise training is less relevant
• Short term risk assessment is less important
• Early post-event exercise testing is less
  relevant
• Intermediate and long term risk assessment and
  management is paramount
• Psychological recovery is paramount
• Patient education is paramount

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The Modern Paradigm in Coronary Disease
Management

• Reduce Risk
• Aggressive Lipid Management
• Smoking Cessation and Abstinence
• Hypertension Control
• Diabetic Control
• Ideal Body Weight
• Restore Confidence
• Physical Capability
• Occupational Capacity
• Sexual Activity
• Increase Knowledge for Self-Care

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Who Gets Rehab - And Who Doesnt

• Does
• Whites, 65-74 years old
• Less than 3 miles away
• Live in the Midwest (54)
• Had CABG (33)
• Older (over 65)
• Overall 20 of eligible

• Doesnt
• Non-whites (33 less)
• More than 6 miles away
• Live in the South (6)
• Had MI (14)
• Younger (50 less likely)
• Overall 80 of eligible

• Basic Coverage
• MI within 12 months, any history of CABG, valve
  surgery, stable angina or heart-lung transplant
• 36 sessions over 12-18 weeks (with up to 72
  sessions)

8
Payment -The First Impediment

• Medicare Reimbursement
• 30 - 40 per patient per session
• 1000 - 1400 for complete program
• Private Insurance
• 80 - 100 per patient per session
• 2800 - 3600 for complete program
• Medicare Supplements
• Intermediate payment to bring total program
  reimbursement closer to private insurance level

9
Program Organization

• Still structured around exercise training
• Stress test or not?
• Intake evaluation
• Exercise prescription
• Risk factor assessment
• Risk factor treatment plan
• Exercise Program (with add-ons)
• Structured exercise training
• Psychological support
• Patient education
• Risk factor management

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The 80 Solution

• 80 of your eligible patients are not going to
  participate in structured cardiac rehabilitation
• Those patients still need many of the services
  offered by cardiac rehabilitation
• Other than monitored exercise, you can provide
  the services they need

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Cardiac Rehab R Us

• Home Exercise Training
• Risk Factor Management
• Lipid Management
• Blood Pressure Management
• Diabetic Control
• Smoking Cessation
• Psychological Support and Self Efficacy
• Patient Education

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Monitored Versus Unmonitored Exercise Training

• Safety
• With appropriate risk stratification (ie.,
  symptom-limited stress test), equally safe
• Efficacy
• Monitored programs have slightly higher exercise
  capacity at 6 weeks
• No difference between monitored and unmonitored
  training at 12 weeks

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Exercise Testing Before Rehab?

• None
• Base program on age predicted heart rate
• Sub-maximal
• Risk stratification
• Correlate heart rate to exercise capacity
• Usually underestimates peak capacity
• Symptom-limited
• Risk stratification
• Measures peak capacity
• Provides more accurate exercise prescription

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Exercise Prescription

• No Stress Test
• Based on 65-85 predicted maximal heart rate
  (PMHR)
• PMHR 220 - age
• Very wide confidence intervals around PMHR
• Stress Test
• Sub-maximal - Based upon estimated peak exercise
  capacity
• Symptom-limited - Based upon actual peak exercise
  capacity

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Exercise Training

• Frequency
• Four times weekly
• Intensity
• 85 of maximal heart rate
• Time
• 30-45 minutes of continuous aerobic exercise
• Safety
• Start low, go slow

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Tips for Unmonitored Training

• Stress test is mandatory for risk stratification
• Symptom-limited stress testing is preferred
• Low risk patients with ischemia exercise at 20
  bpm below ischemic threshold
• Start low, go slow
• The biggest risk is orthopedic injury - warm-up
  and cool-down
• You dont need a 75 jogging suit, 125 pair of
  Nikes or a heart rate monitor
• Avoid very hot and very cold weather

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The Borg ScaleRate of Perceived Exertion (RPE)
6 7 Very, very light 8 9 Very
light 10 11 Fairly light 12 13 Somewhat
hard 14 15 Hard 16 17 Very hard 18 19 Very, very
hard 20
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Manage the NumbersBlood Pressure, Blood
Cholesterol, Blood Sugar

• Blood Pressure
• For most patients, BP lt 130/80 mmHg
• Lipids - Follow the NCEP Guidelines
• For most patients, LDL goal of lt 100 mg/dl
• Blood Sugar
• HgbA1c lt 6.5 (or lt 7)

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Smoking CessationThe 20 Minute Program

• Determine if the patient is ready to quit
• Set a quit date
• Determine degree of nicotine dependence
• How soon after you wake up in the morning do you
  have to have a cigarette?
• Do you have trouble abstaining even where smoking
  is forbidden?
• Do you smoke more in the first few hours after
  waking up than the rest of the day?

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Smoking CessationThe 20 Minute Program

• Prepare to stop smoking
• Get rid of all cigarettes
• Throw away all ashtrays
• Air out the house, detail the car
• Tell your family and friends
• Plan on how you will spend the 100 per month (_at_
  3.81 per pack)

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Smoking Cessation

• Identify linked behaviors and make a plan
• After meals
• Driving
• Talking on the telephone
• Coffee
• Stress
• Alcohol
• Quit with others
• Consider pharmacologic help

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Chantix (Verenicline)

• Blocks nicotine receptors in the brain
• Side-effects
• Nausea (30), other GI symptoms, sleep
  disturbance
• Neuropsychiatric issues
• Contraindications
• Renal failure, pregnancy
• No Clinically Important Drug Interactions
• Effectiveness
• 50 abstinent at 3 months, 25abstinent at 6
  months
• Dosage
• 0.5 mg daily for 3 days, 0.5 mg BID for 5 days, 1
  mg BID through end of treatment (12 weeks)

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Zyban/Wellbutrin (Bupropion)

• Mechanism of action unknown
• Side-effects
• Sleep disturbance (35), dry mouth (10), GI
  symptoms
• Contraindications
• Taking bupropion, seizures, eating disorder,
  alcoholism, neuropsychiatric issues, pregnancy
• Interactions
• MAO inhibitors, drugs metabolized by C450
  (antidepressants, beta-blockers, antiarrhythmics,
  and antipsychotics)
• Effectiveness
• 50 abstinent at 6 months, 25abstinent at 12
  months
• Dosage
• 150 mg daily for 3 days, then 150 mg BID,
  starting two weeks before smoking cessation

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Nicotine Replacement Therapy (NRT)

• Patch, gum, inhaler, nasal spray
• Mechanism is tapering dose of nicotine
• Contraindications
• Relative - Pregnancy, arrhythmias. frequent
  angina
• No known drug interactions
• Effectiveness
• 1.5 - 2 times as effective as counseling alone
• 35 six-month abstinence rate
• Dosage
• Varies by formulation

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Smoking Cessation

• Relapse
• 90 will relapse with at least one cigarette
  within six months
• Have a plan
• Not a failure
• Not an open door to resume smoking
• Make me a promise

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Self Efficacy

• Definition - An individuals belief about his/her
  capability to produce effects
• Low self efficacy predicts failure and an
  unwilling ness to try again
• High self efficacy predicts a willingness to try
  and a resolve to work through failure

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Self Efficacy

• Increasing Self Efficacy
• Mastery experiences - early success, persistent
  effort
• Vicarious experiences - seeing people similar to
  oneself succeed by sustained effort
• Social persuasion - being persuaded verbally that
  one has the capability to succeed
• Four Psychological Processes
• Cognitive - organize thought and rehearse
  experience
• Motivational - causal attribution, outcome
  expectancies, cognized goals
• Affective - coping capabilities
• Selection - activities and challenges patients
  opt to initiate

Bandura, A, Encyclopedia of human behavior, 1994
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Restoring Confidence Using Self Efficacy

• Exercise Training
• Mastery experience - Symptom-limited stress test
• Social persuasion - Tell the patient, based upon
  the stress test that they can safely and
  effectively exercise
• Vicarious experience - Monitored exercise
  programs
• Cognitive - Rehearse success
• Motivational -Relate exercise to improved health
  and capacity, expect fatigue and dyspnea, form
  progressive goals
• Coping - Minimize fear based upon stress test
• Selection - start low, go slow

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Occupational Work

• Average patient eligible for cardiac rehab has an
  exercise capacity of 7-8 METs on a post event
  treadmill test
• Average peak effort for occupational work
  (excluding manual labor) is 3-4 METs
• Average person can easily sustain work at 50 of
  peak capacity for 6-8 hours
• Delayed return to work is more often the
  physicians and spouses fault than the physical
  capacity of the patient

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Self Knowledge for Self Care

• Post Event patients need to know
• How to recognize and treat angina
• When to access 911
• How to recognize and respond to other cardiac
  symptoms, particularly related to heart failure
  and arrhythmias
• What their medications are, what they do, and how
  to take them
• What their medical condition is and how they can
  improve their health

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Sexual Activity

• Requires 2-3 METs capacity pre-orgasmic and 3-4
  METs orgasmic activity
• Average peak heart rate with a familiar partner
  is 120 bpm
• Less than 1 of MIs occur during sexual activity
• Relative risk is increased by recent MI or ACS
• Negative stress test associated with
  significantly lowered risk

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Cardiac Rehabilitation ProgramsA Pitch

• Cardiac Rehab R Us does not really work
• Organized cardiac rehabilitation programs
• Consist of trained and highly skilled individuals
  who love what they do
• Improve patient self-efficacy for physical
  activity, occupational work, sexual activity and
  medication compliance
• Improve patients knowledge about their condition
  and teach them appropriate symptom recognition
  and response
• Cut recovery time by 50