1. Presented By: Sarah Borders, Keri Howard, Justin Klenke, Conner Zuber
Center vs Home Based Cardiac Rehabilitation: Post Myocardial Infarction
Presented By: Sarah Borders, Keri Howard, Justin Klenke, Conner Zuber

2. Introduction Cardiac Rehabilitation Improve Physical Health
Decreased Morbidity and Mortality
20% reduction in all cause mortality
27% in cardiac mortality at 2-5 years
(Dalal, 2010)

3. Introduction Cardiac Rehabilitation
3 year survival rate of participants vs non-pariticipants
Improves prognosis post-MI in cost effective manner
Participation increases long term compliance
Positively affects the basic pathophysiology of CAD and underlying causes
(Williams, 2006)
Completed CR: 3 year survival rate 95% compared to 64% on non complete
Cost effective: reduce recurrent hospitalization and health care expenses
Its important therapuetic modality warrants more widespread application
Basic pathophys: positive affects on CAD, underlying disease process- impacts events of morbidity and mortality

4. Introduction Cardiac Rehabilitation Significant increases in:
VO2
6 Minute Walk Test
Anaerobic Threshold
Positive gains seen in patients with congestive heart failure, etc.
(van Tol, 2006)

5. Introduction Primary Goals of Cardiac Rehabilitation Components
Develop individualized therapuetic plan
Aim of regaining/maintaining optimal status
Components
Home vs Center Based
(Piotrowixz,2008)
Other Goals:
Control of pharmacotherapy
Maintaining optimal mental and physical condition
Reduction of risk factors
Promotion of health lifestyle
Cardiac Rehabilitation Components
Clinical Evaluations
Optimization of Pharmacotherapy
Physical Training
Psychosocial Rehabilitation
Evaluation and Reduction of Risk Factors
Lifestyle Modification
Patient Education

6. Role of Physical Therapist
Minimally involved
1960s: Physical Therapist considered “Exercise Specialist”
1980s: exercise physiology increases in population
Now: small amount of PT’s specialize in Cardiopulmonary fields
Require special training to become program director
Definition of PT training
(William,2008)
Minimally involved directing CR programs and writing prescriptions
RN or exercise physiologist majority of program directors
1960s: become more responsible with exercise prescription
The PTs who do specialze more involved in acute care setting
PT training: “they would particularly qualified to manage complex patietns with cardiac and pulmonary diseases who present with orthopedic or nuerologic co-morbidities

7. Center-Based Cardiac Rehabilitation
Supervised group program undertaken in hospital or community setting
(Dalal, 2010)
Pro’s
Con’s
Pros:
Constant monitoring with trained staff
Group based exercises
Provides equipment which may not be at patients home
Cons:
Pt. must travel to facility
Possibly decreased compliance
Expense

8. Home-Based Cardiac Rehabilitation
Structured program with clear objectives
Completed in patient’s home
Must include PT/Physician monitoring
(Dalal, 2010)
Pro’s
Con’s
Pro’s:
No travel
Completed at patient’s desired time
Increase compliance?
Can be monitored via phone
Less expense
Con’s:
No on site monitoring
Lack of exercise equipment possible
Pt. must be self- motivated
Decrease compliance?

9. Center-Based Research
Combined leg ergometry and circuit training
6 week program
Intensity and duration increased at week 3
Participants completed a home exercise program
(Leitch,1997)
30 minute session (first week) and 60 minutes by third week.
Intensity increased to 70% of max HR by week 3
Participants also completed a home exercise program
5 minutes (week 1) and 30 minutes (week 6) 2x/week

10. Center-Based Research
40 total sessions during a 5 week period
stretching and flexibility exercises
endurance training
(Marchionni, 2003)
Hospital based setting
Comprehensive cardiac rehab programmes
(Jolly, 2003)
Study #2
24 sessions of endurance training on a cycle ergometer: complete 3x a week
16 sessions of stretching and flexability: complete 1 hour sessions 2x a week
STUDY #3
Comprehensive cardiac rehab program consisted of risk factor counseling, relaxation and supervised exercise sessions for 6-12 weeks 1 to 2x a week.

11. Home-Based Research Walking program (considered control group)
(Leitch, 1997)
Received similar exercise prescription as the center-based participants
(Marchionni, 2003)
STUDY #1
Just completed the walking program with no other exercise in order to be a control group (compared to the center based program listed early: combination of leg ergometry and circuit training for 6 weeks, 30 mins for first weeek to 60 mins for third week. Also increased intensity to 70% of mac HR by week 3, also completed a home walking prgram for 30 mins 2x/week in week six and 5 mins 2x/week in week one)
STUDY #2
4 to 8 supervised instruction sessions in the cardiac rehab unit
Received similar exercise prescription as the center based parcipants: center based participants prescription included 40 sessions: 24 (3x a week) of endurance training on a cycle ergometer, and 16 sessions (2x/week) 1 hour sessions of stretching and flexibility exercises
A PT made home visits every other week to adjust if necessary the exercise prescription, to enhance the adherence with intervention, and to record number of completed sessions and distance cycled.

12. Home-Based Research Given a manual, telephone contact, and home visits
Heart manual program for first 6 weeks post MI
Home visits at 1-2 weeks, 6 and 12 weeks
Telephone contact at 3 weeks
(Jolly, 2003)
STUDY #3
The heart manual: this is a facilitated home-based programme for the first 6 weeks following MI, which included education, a home based exercise prgramme, and a tape-based relaxation and stress management programme
Telephone contact at 3 weeks during which the rhav nurse discusses the contents of the manual with the patient and partner and sets individual objectives with the patient with respect to smoking cessation, diet and exercise

13. Results
Peak oxygen and endurance increased in the exercise groups. (Leitch, 1997)
Home and center based showed similar improvements in:
Exercise capacity
Systolic blood pressure and serum cholesterol
Reduced hospital admits and increased QOL (home heart manual only)
(Jolly, 2003)
STUDY #1 (Leitch et al)- where home walking program was used as a control group
Results showed minimal additional benefits on cardiac autonomic function compared with a standard home walking program
An additional supervised exercise training does not appear to result in clinically significant changes in cardiac autonomic function compared with a home walking program.
STUDY #2
Home based programme using the heart manual reported significantly reduced hospital admissions and report a significantly improved QOL compared to center based.

14. Results Improvements in both settings continued: Home based
Total work capacity (TWC)
Exercise tolerance
Heart related quality of life (HRQL)
Home based
Cost saving and better permanent changes in lifestyle
Higher drop out rates
(Marchionni, 2003)
Post MI cardiac rehab enhances exercise tolerance in all patients of all ages
Costs for center based was $21,298, while it was $13,246 for home Cardiac rehab. Home CR was associated with cost savings more than hospital
Home cardiac rehab with implicit self management of the exercise program, induces a permanent change in lifestyle more effectively than hospital cardiac rehab.

15. Results Exercise capacity Short term showed no difference
Long term showed better results with home based
(Dalal, 2010)
Pooled analysis across all studies showed no significant differences in short term exercise capacity between home and center based CR
Pooled analysis of three studies reported longer term data (14-24 months) that exercise capacity was better with home based CR.

16. Exercise Capacity Comparisio
(Dalal, 2010)

17. Patient Preference (Dalal, 2010)
Patient’s preference has been hypothesized to have an impact on uptake and adherence to home based vs center based CR. This meta anlysis states that patients were split on setting preference.
This meta analysis found no difference between the 2 groups, regarding postive physical performance benefits. We agree that there is no true optimal setting to complete cardiac rehab. There are mutliple factors patients must consider when deciding which setting is best for him/her.
(Dalal, 2010)

18. Further Benefits for Cardiac Rehab
Patients were coronary artery bypass graft.
Shows beneifts of CR outside of MI
Can’t conclude that center based is better for any heart complication based on this graph.
Just proves that CR is beneficial in increasing exercise capacity when patients complete.
(Arthur,2002)

19. Conclusion Any exercise is better than nothing
Positive physical benefits similar in both settings
Programs must be patient specific
Questions?
Cardiac Rehabilitation

20. References
 Arthur H, Smith K, Kodis J, McKelvie R. A controlled trial of hospital versus home-based exercise in cardiac patients. / Comparaison lors d ' une etude controlee d ' exercices pratiques a domicile et d ' exercices pratiques a l ' hopital chez des patients cardiaques.Medicine & Science In Sports & Exercise [serial online]. October 2002;34(10): Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed November 22, 2013.
Dalal H, Zawada A, Jolly K, Moxham T, Taylor R. Home based versus centre based cardiac rehabilitation: Cochrane systematic review and meta-analysis. BMJ (Clinical Research Ed.) [serial online]. January 19, 2010;340:b5631. Available from: MEDLINE, Ipswich, MA. Accessed November 10, 2013.
Jolly K, Lip G, Stevens A, et al. Home-based versus hospital-based cardiac rehabilitation after myocardial infarction or revascularisation: design and rationale of the Birmingham Rehabilitation Uptake Maximisation Study (BRUM): a randomised controlled trial [ISRCTN ]. BMC Cardiovascular Disorders [serial online]. September 10, 2003;3:10. Available from: MEDLINE, Ipswich, MA. Accessed November 10, 2013.
Leitch J, Newling R, Basta M, Inder K, Dear K, Fletcher P. Randomized trial of a hospital-based exercise training program after acute myocardial infarction: cardiac autonomic effects. Journal Of The American College Of Cardiology [serial online]. May 1997;29(6): Available from: MEDLINE, Ipswich, MA. Accessed November 10, 2013.
Marchionni N, Fattirolli F, Masotti G, et al. Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction: results of a randomized, controlled trial.Circulation [serial online]. May 6, 2003;107(17): Available from: CINAHL, Ipswich, MA. Accessed November 10, 2013.
Piotrowicz R, Wolszakiewicz J. Cardiac rehabilitation following myocardial infarction. Cardiology Journal [serial online]. 2008;15(5): Available from: MEDLINE, Ipswich, MA. Accessed November 10, 2013.
van Tol B, Huijsmans R, Kroon D, Schothorst M, Kwakkel G. Effects of exercise training on cardiac performance, exercise capacity and quality of life in patients with heart failure: a meta-analysis. European Journal Of Heart Failure [serial online]. December 2006;8(8): Available from: MEDLINE, Ipswich, MA. Accessed November 17, 2013.
Williams M, Ades P, Squires R, et al. Clinical evidence for a health benefit from cardiac rehabilitation: an update. American Heart Journal [serial online]. November 2006;152(5): Available from: MEDLINE, Ipswich, MA. Accessed November 17, 2013.