1. Risk Factor Modification in CCR. How does CR work?

2. Outline Elements of CR Risk Factors Pharmacotherapy Exercise-based and Comprehensive CR as effective therapy –Mortality and Morbidity –Risk factor reduction

3. Outline Psychological Interventions as an adjunct to CCR Other potential ‘interventions’ –Things there aren’t (yet) drugs for: Psychosocial Effects QoL Functional capacity*

4. Comprehensive Model (CCR) Comprehensive Cardiac Rehabilitation Services Psychosocial/ Vocational Counselling Exercise Training Risk Factor Modification Medical Surveillance Emergency Support

5. Pharmacologically Modifiable Risk Factors High blood cholesterol –Statins High blood pressure –ACE-inhibitors, Ca+ channel inhibitors, beta-blockers Diabetes mellitus –Insulin Obesity and Overweight –Orlistat

6. ‘Psychologically’ Modifiable Risk Factors (Lifestyle Factors) Smoking Physical inactivity Obesity and overweight* –Problems High blood cholesterol* –Problems Diabetes mellitus* –*Via diet therapy

7. Physiologically Modifiable Risk Factors High blood pressure High blood cholesterol Diabetes mellitus Obesity and overweight Physical inactivity* –Via lifestyle modificaiton

8. Efficacy of Pharmacological Interventions Meta-analytical level evidence available for mortality/risk factor reduction: –Statins, –Beta-blockers, –ACE-inhibitors, –Ca+ channel agonists

9. Efficacy of Pharmacological Interventions Meta-analytical level evidence available for alterations in: –Homocysteine Folic Acid B-6 & B-12 –Platelet Function Aspirin

10. Polypill anyone?

11. A strategy to reduce cardiovascular disease by more than 80% N J Wald, M R Law (2003) http://bmj.com/cgi/content/full/326/7404/1419

13. Exercise only CR: Positive Outcomes for All cause mortality Total cardiac deaths Non-fatal MI, PTCA/CABG

14. Efficacy of Exercise-based Interventions Pooled Outcomes for Risk Factors

17. Comprehensive CR: Positive Outcomes for Total cardiac deaths Non-fatal MI, PTCA/CABG

20. Taylor et al. 2004 Am J Med. 2004 May 15;116(10):682-92

21. Significant Changes in Modifiable Risk Factors TC ( -0.37 mmol/L; 95% CI: -0.63 to -0.11 mmol/L) TG (-0.23 mmol/L; 95% CI: -0.39 to -0.07 mmol/L SBP (-3.2 mm Hg; 95% CI: -5.4 to -0.9 mm Hg) Smoking (OR = 0.64; 95% CI: 0.50 to 0.83)

22. Modifiable Risk Factors Without Evidence of Change –LDL-C (-0.20 mmol/L; 95% CI: -0.53 to 0.12 mmol/L –HDL-C (-0.05 mmol/L; 95% CI: -0.03 to 0.14 mmol/L) –DBP (-1.18 mmHg; 95% CI: -2.68 to 0.32) mmHg

23. Modifiable Risk Factors (cont) Health related quality of life (QoL): n=12 reviewed but no meta-analysis (high variation in methodology) General conclusion: –Improvement in QoL with CR but improvement also in controls (in 10/12 trials)

24. Discussion: Mortality & Morbidity Exercise-based CR works Little additional benefit from lifestyle management

25. Discussion: Risk Factors Evidence for exercise-based and comprehensive CR for –SBP (but not DBP) –Lipids? –QoL* *Not risk factor –Smoking Question: ‘Is there an additional benefit from psychological interventions in CCR’.

26. Efficacy of Psychological Interventions in CCR. Is there an additional benefit from psychological interventions in CCR’.

28. Efficacy of Psychological Interventions Pooled Outcomes for Clinical End Points

33. Efficacy of Psychological Interventions Pooled Outcomes for Risk Factor: Lipids

38. Efficacy of Psychological Interventions Pooled Outcomes for Risk Factor: Blood Pressure

41. Efficacy of Psychological Interventions Pooled Outcomes for Risk Factor: Smoking

43. Efficacy of Psychological Interventions Pooled Outcomes for Psychological Measures

47. Conclusions Strong evidence for pharmacological interventions Mortality Morbidity reduced with just exercise Additional effect of Exercise/CCR –Some lipids –Smoking –QoL?

48. Conclusions Additive effects of psych: –TC, LDL, SBP Additional effects of psych: –Anxiety? –Depression –HDL –DBP

49. Magic? Psychosocial effects difficult to quantify ‘Rub-off’ of being in a group Associated acitivities Magic.